1. health and fitness
2. disease

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chapter
20
Peripheral Angiography
Sohail Ikram, MD / Massoud Leesar, MD / Ibrahim Fahsah, MD
•
raphy to an operator interested in treating patients with
PAD.
PERIPHERAL ANGIOGRAPHY
Peripheral arterial disease (PAD) comprises a host of noncoronary arterial syndromes due to various pathophysiological mechanisms resulting in stenosis or aneurysms in
various vascular beds. Atherosclerosis (AS) remains by far
the most common cause of this disease process. According to the recently released ACC/AHA guidelines for the
management of patients with PAD, it is a major cause of
decrement of functional capacity, quality of life, limb amputation, and increased risk of death.1
Millions of people worldwide are afflicted with this
syndrome.2,3 While awareness for coronary artery disease
(CAD) has significantly increased in the last decade, the
awareness, diagnosis, and treatment of PAD remain much
underappreciated. With improvement in catheter-based
and imaging technology, it was only natural that all specialties involved in the management of vascular disease would
involve endovascular therapy of this potentially disabling
and lethal disorder.4−6
Excellent reviews on PAD are already available in the literature. The ACC/AHA guidelines, Trans Atlantic Society
Conference (TASC) Working Group document,7 the ACC
COCATS-2 Paper,8 provide the basic fundamental material for a physician interested in the management of patients suffering from PAD. Based on literature review and
our own experience at the Washington Hospital Center,
Washington, DC, and University of Louisville, Louisville,
KY, we have tried to focus in this chapter on the general
principles of performing invasive peripheral angiography.
We have also briefly described noninvasive imaging modalities of computed tomographic angiography (CTA), magnetic resonance angiography (MRA), and carbon dioxide
(CO2 ) angiography as their utility relates to each vascular
bed. The full details of these other modalities are, however,
out of the scope of this chapter. We hope that this chapter
will provide the basic understanding in catheter angiog-
Training Requirements
There are considerable differences of opinion that exist among various specialties regarding the optimal training required before certifying operators to safely perform
peripheral vascular procedures.9−16 Specialties including
interventional cardiology, interventional radiology, vascular surgery, interventional neuroradiology, interventional
nephrology, and interventional neurosurgery all possess basic and unique knowledge that positions them to advance
their skills into peripheral angiography and interventions.
The ACC COCATS-2 (Tables 20-1 and 20-2) provides
guidelines for a cardiovascular trainee who wishes to be
certified in the performance of such procedures.
A minimum of 12 months of training is required. Completion of 100 diagnostic angiograms and 50 peripheral vascular interventions has been recommended for unrestricted
certification. Fifty percent of such procedures should be
performed as “primary operator” under the guidance of a
mentor who is certified in peripheral vascular interventions.
Prior to the performance of invasive procedures, this physician should be knowledgeable in vascular medicine and
noninvasive modalities in the diagnosis of peripheral vascular disorders. Before signing off the certificate, the mentor
should require the trainee to have exposure in the angiography of various vascular beds. This should also include cases
of vascular thromboses and their treatment. Carotid and
vertebral artery angiography is excluded from most general guidelines and added skills are required in this vascular
territory. The ACC/ACP/SCAI/SVMB/SVS Clinical Competent Statement outlines these requirements (Tables 20-3
and 20-4).
Restricted certificates can be awarded to physicians who
achieve satisfactory skills in only certain vascular territories.
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342 • CHAPTER 20
TABLE 20-1. Training in Diagnostic
Cardiac Catheterization and
Interventional Cardiology
TABLE 20-3. Formal Training to Achieve
Competence in Peripheral Catheter-Based
Interventions
Level 1—Trainees who will practice noninvasive
cardiology and whose invasive activities will be
confined to critical care unit procedures.
Level 2—Trainees who will practice diagnostic but
not interventional cardiac catheterization.
Level 3—Trainees who will practice diagnostic and
interventional cardiac catheterization.
Training requirements for cardiovascular physicians
r Duration of training∗ —12 months
r Diagnostic coronary angiograms† —300 cases (200
as the primary operator)
r Diagnostic peripheral angiograms—100 cases (50
as primary operator)
r Peripheral interventional cases§ —50 cases (25 as
primary operator)
Training requirements for interventional radiologists
r Duration of training‡ —12 months
r Diagnostic peripheral angiograms—100 cases (50
as primary operator)
r Peripheral interventional cases§ —50 cases (25 as
primary operator)
Maintenance of certification is also required by continuous
medical education and performance of 25 peripheral vascular interventions per year. For full details, the reader may
refer consensus conference guidelines.17
•
Training requirements for vascular surgeons
r Duration of training—12 months||
r Diagnostic peripheral angiograms¶ —100 cases (50
as primary operator)
r Peripheral interventional cases§ —50 cases (25 as
primary operator)
r Aortic aneurysm endografts—10 cases (5 as
primary operator)
NONINVASIVE IMAGING
Noninvasive imaging is improving at a rapid pace and is
replacing routine catheter angiography in many cases.
Magnetic Resonance Angiography
According to the ACC/AHA guidelines, MRA with
gadolinium contrast is now a Class I indication (conditions for which there is evidence for and/or general agreement that a given procedure or treatment is beneficial, useful, and effective) and level of evidence A (data derived
from multiple randomized trials or meta-analysis) to diagnose the anatomic location and degree of stenosis in the
lower extremity PAD; and to select patients who are candidates for endovascular or surgical revascularization. MRA
has Type IIb indication (conditions for which there is conflicting evidence and/or divergence of opinion about the
usefulness/efficacy of a procedure or treatment. Weight
of evidence/opinion is in favor of usefulness/efficacy) and
level of evidence B (data derived from a single randomized trial or nonrandomized trials) in patients with PAD
to select surgical sites for surgical bypass and for postsurgical and postendovascular revascularization surveillance.
Gadolinium is less nephrotoxic and there is no exposure to
This table is consistent with current Residency Review Committee
requirements.
∗
After completing 24 months of core cardiovascular training and 8
months of cardiac catheterization
†
Coronary catheterization procedures should be completed prior to
interventional training.
‡
After completing general radiology training.
§ The case mix should be evenly distributed among the different vascular beds. Supervised cases of thrombus management for limb ischemia and venous thrombosis, utilizing percutaneous thrombolysis
or thrombectomy should be included.
In addition to 12 months of core vascular surgery training.
¶In addition to experience gained during open surgical procedures.
ionizing radiation. Currently utilized techniques of MRA
include time of flight (TOF), three-dimensional imaging,
contrast enhancement with gadolinium subtraction, cardiac
gating and bolus chase.18 With the contrast-enhanced MRA
(CE MRA), the sensitivity is 90% and specificity 97% in
TABLE 20-2. Summary of Training Requirements for Diagnostic and Interventional Cardiac
Catheterization
Level
1
2
3
∗
Duration of
Training (mo)
Cumulative Duration
of Training (mo)
4
4
12
4
8
20
Minimum no. of Procedures
Diagnostic
Interventional
100
200
0
Only one level 1, 2, or 3 trainee may claim credit for a procedure. See text for explanation.
0
0
250
Cumulative no. of Examinations
Diagnostic
Interventional
100
300
300
0
0
250
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PERIPHERAL ANGIOGRAPHY • 343
TABLE 20-4. Alternative Routes to Achieving Competence in Peripheral Catheter-Based
Intervention∗
1. Common requirements
a. Completion of required training within 24-month period
b. Training under proctorship of formally trained vascular interventionalist competent to perform full range of procedures
described in this document
c. Written curriculum with goals and objectives
d. Regular written evaluations by proctor
e. Documentation of procedures and outcomes
f. Supervised experience in inpatient and outpatient vascular consultation settings
g. Supervised experience in a noninvasive vascular laboratory
2. Procedural requirements for competency in all areas
a. Diagnostic peripheral angiograms—100 cases (50 as primary operator)
b. Peripheral interventions—50 cases (25 as primary operator)
c. No fewer than 20 diagnostic/10 interventional cases in each area, excluding extracranial cerebral arteries†
d. Extracranial cerebral (carotid/vertebral) arteries—30 diagnostic (15 as primary operator)/25 interventional (13 as
primary operator)
e. Percutaneous thrombolysis/thrombectomy—5 cases
3. Requirements for competency in subset of areas (up to 3, excluding carotid/vertebral arteries)
a. Diagnostic peripheral angiograms per area—30 cases (15 as primary operator)
b. Peripheral interventions per area—15 cases (8 as primary operator)
c. Must include aortoiliac arteries as initial area of competency
∗
The fulfillment of requirements via an alternative pathway is only appropriate if the candidate physician has the cognitive and technical skills outlined in
Table 20-4 and is competent to perform either coronary intervention, interventional radiology, or vascular surgery. These alternative routes for achieving
competency are available for up to 5 years following publication of this document.
†
Vascular areas are (1) aortoiliac and brachiocephalic arteries, (2) abdominal visceral and renal arteries, and (3) infrainguinal arteries.
Reproduced, with permission, from Creager MA, Goldstone J, Hirshfeld JW Jr, et al. ACC/ACP/SCAI/SVMB/SVS clinical competence statement on vascular medicine and catheter-based peripheral vascular interventions: a report of the American College of Cardiology/American Heart Association/American
College of Physician Task Force on Clinical Competence (ACC/ACP/SCAI/SVMB/SVS Writing Committee to develop a clinical competence statement
on peripheral vascular disease. J Am Coll Cardiol. 2004;44(4):941-957.
lower extremities PAD as compared to digital subtraction
angiography (DSA).19−21 Runoff vessels may, in fact, be
better visualized with MRA than DSA.22,23 In the patients
diagnosed with critical limb ischemia (CLI), with intraoperative angiography as the standard, MRA had comparable accuracy to standard catheter angiography. Sensitivity
and specificity for patent vessels was 81% and 85%, respectively. For the identification of segments suitable for
bypass grafting, the sensitivity of contrast angiography was
less than MRA (77% vs. 82%), but the specificity was better (92% vs. 84%).24 A meta-analysis of MRA compared to
catheter angiography for stenoses >50% showed that the
sensitivity and specificity were 90% to 100%, especially
when gadolinium was used.25 Recent studies also show
an agreement of 91% to 97% between MRA and catheter
angiography.26
MRA, however, tends to overestimate the degree of
stenosis and occlusions. It might also be inaccurate in assessing lesions with stents. Another limitation is in patients
who have been implanted with automatic defibrillators,
permanent pacemakers or who have intracranial coils or
clips.27,28 In these patients, MRA is generally contraindicated. Gadolinium is generally considered nonnephrotoxic,
but one study reported nephrotoxicity in patients with
baseline renal dysfunction.29 A significant number of pa-
tients are also severely claustrophobic during imaging and
require alternative testing.
Computed Tomographic Angiography
CTA is considered by ACC-AHA guideline committee to
merit a Type IIb indication (usefulness/efficacy is less well
established by evidence/opinion) and level of evidence B for
diagnosing the anatomic location and presence of stenoses
in patients with lower extremity PAD. It is considered as a
substitute for MRA in patients who have contraindication
to MRA.30−34
This technique was first started in 1992. Image acquisition is very rapid. Images can be rotated in three dimensions, thus bringing into view eccentric lesions that
might be missed by two-dimensional catheter angiography. Older scanners had a single detector that acquired
one cross-sectional image at a time and was very timeconsuming. It also required more contrast load and there
was overheating of the X-ray tube. The currently available
multidetector CT (MDCT) scanners can acquire 64 slices
simultaneously.34−39 Abdominal aorta and the entire lower
extremity can be imaged in less than 1 minute.40 One hundred to one hundred eighty milliliters of iodinated contrast
is injected at 1 to 3 mL per minute via a peripheral venous
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line. The radiation exposure is typically one-quarter of that
in catheter angiography.
With the single detector scanners, the sensitivity for occlusions was 94% and specificity was 100%. For stenoses
greater than 75%, the sensitivity and specificity dropped
significantly to 36% and 58%, respectively, when maximum intensity projection was used and improved to 73% to
88% when each slice was individually analyzed. With the
MDCT, the sensitivity for stenoses greater than 50% was
89% to 100% and the specificity was 92% to 100%.
CTA is useful in selecting patients who are candidates for
endovascular or surgical revascularization. It also provides
useful information about associated soft tissue structures
that may affect decision making in the optimal endovascular treatment of PAD, e.g., vascular aneurysms. In one study,
it showed that popliteal artery stenosis and occlusions occurred because of aneurysms, cystic adventitial disease, or
entrapment.41 Other advantages are patient comfort, and
compared to DSA, it is noninvasive, less expensive, delivers less radiation (approximately one-fourth) and has better
contrast resolution.42
The major limitation of CTA is the risk of contrastinduced nephropathy (CIN). Other drawbacks include lack
of accuracy with single detector scanners, lower spatial resolution than DSA, venous filling obscuring arterial imaging, decreased accuracy in calcified vessels, and asymmetrical opacification of legs. The accuracy and effectiveness of
CTA is not as well delineated as that of an MRA. Treatment
plans based on CTA have not been compared with those of
contrast angiography in lower extremity PAD.
Carbon Dioxide Angiography
CO2 angiography is not available in most centers and generally reserved for patients with history of contrast allergy or
renal dysfunction with creatinine clearance less than 20 mL
per minute. The use is generally limited to arteries below
the diaphragm to minimize the risk of cerebral embolism.
DSA equipment is required for CO2 angiography.43−50
•
CONTRAST ANGIOGRAPHY
In spite of tremendous improvements in noninvasive imaging, catheter-based invasive iodine contrast catheter angiography remains the gold standard for the diagnosis of
PAD in patients considered for endovascular intervention.
It is the most widely available modality for the imaging of
the vasculature. It is the only universally accepted technology for guiding percutaneous peripheral vascular interventions. Millions of angiographic procedures have been performed worldwide since William Forssman in 1929 passed
a catheter from his own arm vein into his right atrium.51
In the early period, direct punctures of the vessels of interest were performed.52 This technique has essentially been
abandoned and replaced by percutaneous needle access.
Safe and good quality angiography requires adequate equipment, well-trained team of staff, and strict adherence to
well-established principles.
Catheter angiography has a Class I ACC/AHA indication for delineating the anatomy in patients who require
revascularization. Modern technology has permitted the
use of smaller diameter sheaths and catheters, less toxic
contrast agents, better imaging equipment in angiographic
suites requiring less contrast load, thus decreasing the risks
to the patient for adverse effects. Invasive angiography procedures, however, are still associated with rare but potentially devastating complications. The risk of severe contrast
induced reaction is 0.1%.53,54 There is significant risk of
CIN in patients with baseline renal dysfunction, patients
with diabetes mellitus, those with low cardiac output states
or those who are dehydrated. Any combination of these is
more adverse than an individual risk factor.
Informed consents should be obtained prior to the procedure from all patients after fully explaining all the risks, benefits, and alternatives. History of contrast-related allergic
reactions should be documented and appropriate pretreatment should be administered. Decisions regarding revascularization should be made with complete anatomic assessment of the affected arterial territory including imaging of
the occlusive lesion as well as of the inflow and outflow vessels. Noninvasive imaging techniques should be combined
with vascular imaging for the information. DSA should be
used to eliminate dense background tissues. Selective and
superselective catheter placement should be done for better
enhancement of vasculature and to reduce the contrast load
and radiation exposure. Imaging should be done in multiple angulations to uncover vessel overlap, and transstenotic
pressure gradients be measured in ambiguous lesions. In patients with renal dysfunction, appropriate hydration should
be given prior to the procedure. Patients should be followed
up within 2 weeks of the procedure to assess their renal
function, the access site, and to make sure that they have
not suffered adverse effects like atheroembolism.
Radiological Equipment
Peripheral angiography frequently requires imaging of large
areas, which in the absence of a large field of view, will require multiple injections and significant contrast load. A
14-inches (36-cm) image intensifier is recommended (Figure 20-1). Cineangiography at 15 to 30 frames per second (FPS) is excellent for imaging of the moving beating heart.55 Imaging of static structures with radioopaque
bones in the background, e.g., blood vessels, especially the
smaller branches will be suboptimal with this technique.
Therefore, the technique of DSA should be utilized for
peripheral angiography. In this technique, the patient is
required to stay motionless during images; otherwise the
image will be distorted. In carotid angiography, the patient should also be instructed not to swallow to prevent
motion. In modern angiographic suites, ability to acquire
DSA images has cut down on the contrast and radiation
exposure. In DSA, a precontrast “mask” image is first obtained. Following contrast injection, subtraction of this image allows enhanced filling of the vasculature with masking of nonvascular structures like bones, air, and calcium.
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PERIPHERAL ANGIOGRAPHY • 345
1
5
2
3
4
6
7
• FIGURE 20-1.
Peripheral angiography suite at University
of Louisville, Louisville, KY. (1) Fifteen-inch image intensifier;
(2) live monitor; (3) reference monitor; (4) hemodynamic
monitor; (5) equipment adjustment monitor; (6) fractional flow
reserve (FFR) (RADI Sweden) monitor; (7) long patient bed.
Gadolinium or CO2 angiography should be done in laboratories equipped with DSA; otherwise, the image quality is likely to be poor. “Road mapping,” also called “trace
subtract fluoroscopy,” is usually available in catheter laboratories equipped with DSA capability. This is a very useful technique during interventional procedures. This can
be conceptualized as fluoroscopy without the radioopaque
background. A small amount of contrast is first injected to
fill the vessel and the image is stored in memory as a mask.
When the catheter is advanced under normal fluoroscopy,
this mask is subtracted, thus allowing visualization of both
the moving catheter and the vessel. The image in road mapping will appear white in contrast to DSA, where it will be
black. Additional software, enabling quantitative angiography to measure lesion length and diameter should also be
ideally available in current angiographic suites.
Examination Console
Highest kilovoltage peak (KVP) is required for cerebral and
abdominal angiography, lowest for the extremities, and intermediate for the thorax. Frame rate is generally 2 to 3 FPS
for arterial imaging. It is decreased for venous imaging due
to long cine runs. Frame rate is increased for cases requiring
gadolinium contrast. Newer laboratories will typically have
the settings on the console that can be adjusted to optimize
adequate imaging of each vascular bed.
In the imaging of the legs 12- to 15-inch image intensifier is required. A longer table is also desirable. Where these
are not available, the patient can be positioned in reverse
with feet facing the head end of the table. Multiple injections maybe required in the legs to image all the arteries.
Depending on the operator and the staff experience, either
a “stepped mode” method, which requires contrast bolus
at each imaging site, or an “interactive” method where a
single bolus of contrast is given in the abdominal aorta and
the table is automatically set to “chase” down the bolus all
the way to the feet are utilized for angiography. In our own
experience, the stepped mode technique produces better
images with the flexibility of changing the amount of contrast and angles during imaging. It may however require
slightly larger contrast load and exposes operators to more
radiation.
In the “interactive” method, after the bolus is given, a
DSA run of both the lower extremities is obtained followed
by a “dry run” used for subtraction. This technique is sometimes limited by unequal visualization of both legs in larger
patients or in the patients who have flow-limiting lesions
in a segment of the vessel causing delayed filling distally.
Patients may also be unable to lie motionless or hold their
breath for the entire duration of the time required for imaging of all the segments. If free movement of the table is not
confirmed prior to the automatic runs, there is a danger
of pulling out of the imaging catheter and the sheath. We
recommend suturing the sheath if using this method.
Radiation Exposure
Peripheral angiography procedures are typically more time
consuming than coronary procedures. Frustration can easily
set in during a difficult case especially if the staff is not completely familiar with the equipment and trouble shooting
of the modalities commonly used, e.g., DSA, road mapping, bolus chase etc. Also, many laboratories have trainee
fellows and less experienced operators trying to learn this
increasingly popular skill. Basic principles to prevent radiation exposure can thus be overlooked.
Maximizing distance from the X-ray source is the best
way to reduce exposure. Most procedures by the righthanded individuals are done from the right side of the table.
Right anterior oblique (RAO) angulation moves the X-ray
tube away from the operators, thus exposing them to less
radiation than left anterior oblique (LAO) angles. Protective lead shields, good-quality lightweight aprons, thyroid
collars, and leaded eyeglasses should be used as a habit. Use
of DSA and road mapping will further cut down on flourotime. Radiation badges should monitor radiation exposure
of each operator and staff.
Intravenous Contrast Agents
All current contrast agents are iodine-based. The high
atomic number and chemical versatility of iodine makes it
ideal for vessel opacification.56 They are classified as ionic or
nonionic and further differentiated into high-osmolar, isoosmolar, and low-osmolar based on their osmolality. Lowand iso-osmolar agents cause fewer side effects, e.g., hypotension, bradycardia, angina, nausea, and vomiting. They
also cause less heat sensation and are better tolerated in
peripheral angiography. The nonionic agents cause less allergic side-effects and may also be less nephrotoxic. The
nonionic, hypo-osmolar and iso-osmolar agents are more
expensive.57−60 Some patients maybe intolerant to pain and
heat sensation even with the iso-osmolar agents. A 50:50
mixture with saline using DSA imaging can be used in such
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cases. Many agents are commercially available in the market based on their ratio of iodine to ions and concentration
of sodium (that determines their osmolality).
High-osmolar ionic ratio 1.5 agents contain three atoms
of iodine for every two ions, e.g., Renografin (Bracco), Hypaque (Nycomed), and Angiovist (Berlex). Their sodium
concentration is roughly equal to that of blood, making
their osmolality very high (>1500 mosm/kg). They cause
significant pain and are generally not tolerated well by patients undergoing peripheral angiography.
Low-osmolar ionic ratio-3 agents have three atoms of
iodine for every one ion and are low osmolality agents. Their
osmolality is roughly twice that of blood, e.g., Ioxaglate
(Hexabrix, Mallinckrodt).
Low-osmolar nonionic ratio-3 agents are water-soluble
and do not have any ions, e.g., Iopamidol (Isovue, Bracco),
Iohexol (Omnipaque, Nycomed), Ioversol (optiray, Mallinckrodt). Their osmolality is also twice that of blood and
cause burning in many patients.
Iso-osmolar nonionic ratio-6 agents have osmolality
equal to that of blood (290 mosm/kg). They are very well
tolerated by patients. Most commonly used is Iodixinol
(Visipaque, Nycomed). It has fewer incidences of allergic
• FIGURE 20-2.
Micropuncture kit.
reactions than Ioxaglate and has shown no major increase in
adverse coronary events like intravascular thrombosis, vessel closure, or perioperative myocardial infarction.61 There
is also some data suggesting less nephrotoxicity with them.
In all patients with renal dysfunction, intravenous hydration with normal saline at 1 mL/kg/h along with Nacetylcysteine (mucomyst) 600 mg orally twice a day
should ideally be started 12 to 24 hours prior to the procedure. Gadolinium contrast or CO2 angiography is another
option in such patients.
Diagnostic Catheters and Guide Wires
Vascular access is commonly obtained with an 18-gauge
needle that will accommodate most 0.038 inch or smaller
wires. A smaller 21-gauge needle with a 0.018-inch wire is
available in “micropuncture kit” (Cook, Bloomington, IN)
that can be used for difficult femoral, brachial, radial, or
antegrade femoral approaches (Figure 20-2). For a nonpalpable pulse Doppler, integrated needle (smart needle) can
be used. Wires are available in 0.012 to 0.052 inch in diameter. Most commonly used are wires of 0.035 and 0.038
inch. In a standard guide wire, a stainless steel coil surrounds
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• FIGURE 20-3.
Angiography selective catheters.
a tapered inner core. A central safety wire filament is incorporated to prevent separation in case of fracture. Typically
they are 100 to 120 cm in length but can also be 260 to
300 cm. Wires are available when wire position needs to
be maintained for catheter exchanges. Long wires are frequently required in peripheral angiography, more so than in
coronary angiography and their use is encouraged when in
doubt.
The tip of the wires can be straight, angled, or J-shaped.
Some wires have the capability of increasing their floppy
tip by having a movable inner core. Varying degrees of shaft
stiffness, e.g., extra support, to provide a strong rail to advance catheters in tortuous anatomy versus extremely slick
hydrophilic with low friction for complex anatomy have
made peripheral vascular angiography and interventions a
viable and many times a preferred treatment of PAD.
Every angiographic suite should have an inventory of
such wires. The 0.035-inch wires used in our laboratory
are standard J-shaped, Wholey, Straight and Angled Glide,
Amplatz Super Stiff, and Supracore. Among the 0.018-inch
wires inventory are the Steel Core and V18 Control. In
addition to 0.014-inch coronary wires, we frequently use
Sparta Core wire in renal and other peripheral vascular
interventions. Glide wire (Terumo wire) is very useful in
tracking most vessels but carries the risks of vessel dissection
and perforation. It should not be used to traverse needles
because of the potential of shearing.
Numerous catheters are available (Figures 20-3 to 20-5)
and every operator should develop his own skill and “feel”
of catheters he uses in peripheral angiography. An “ideal
catheter” should be able to sustain high-pressure injections,
to track well, be nonthrombogenic, have good memory, and
should torque well.62 Catheters are made of polyurethane,
polyethylene, Teflon or nylon. They have a wire braid in the
wall to impart torquibility and strength. They are available
in different diameters and lengths. They can have an end
hole, side holes, or both end and side holes. When using
the femoral approach, short-length catheters (60–80 cm)
are adequate for angiography of the structures below
the diaphragm, whereas long catheters (100–120 cm)
are needed for carotid artery, subclavian artery, or arm angiography. Five- to six-French catherter (1-F catheter =
0.333 mm) diameter catheters are most commonly used.
Three- to four-French catheters are used for smaller vessels. Side-hole catheters are safe and allow large volume
of contrast at a rapid rate with power injectors, e.g. pigtail,
Omniflush, Grollman. They are commonly used for angiography of ascending aorta, aortic arch, and abdominal aorta.
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• FIGURE 20-4.
Angiography selective catheters.
End-hole catheters are very useful in selective angiography
using manual hand injections. For DSA, 5-F catheters are
sufficient.
Omniflush catheter can be advanced over the wire beyond the aortic bifurcation and then pulled back to engage
the contralateral common iliac artery for selective angiography of the leg. For type-1 aortic arch, a 5 F JR4 will
be adequate for carotid, vertebral, subclavian artery angiography, and for nonangulated renal arteries. Simmons,
Vitek, SOS, and Amplatz catheters are very useful in certain situations but require added skills and careful manipu-
lation. Heparin should be used with the use of these latter
catheters. Simple curved catheters, e.g., Berenstein, Cobra,
and Headhunter, are also useful in angulated renal arteries
and vertebrals.
Vascular Access
Meticulous technique to achieve vascular access is essential
for a successful angiographic procedure. In patients with
PAD, the success or failure of a procedure will significantly
depend on the correct choice of access site. Every effort
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• FIGURE 20-5.
Angiography selective catheters.
should be made to learn the vascular anatomy and direction of blood flow if the patient had previous bypass graft.
Prior noninvasive studies like MRA, CTA, and Duplex ultrasonography (US) should be reviewed prior to the angiography. Peripheral bypass grafts in general should not be
punctured for 6 to 12 months after surgery.
Most common vascular sites are common femoral artery
(CFA) and brachial artery (BA).63,64 Fluoroscopy should be
routinely used to identify bony landmarks to avoid puncturing the artery too low or too high.
Femoral Approach
CFA is ideally suited because of its large caliber that can
accommodate up to 14-F sheaths percutaneously and its
central location, enabling access to all vascular territories.
When compared to the arm approach, there is less radiation
exposure but more incidence of bleeding and delayed ambulation. Both retrograde (toward the abdomen) and antegrade (toward the feet) CFA punctures are routinely done.
For the antegrade approach, micropuncture technique using 21-gauge needle with 0.018-inch wire is recommended.
It should always be done under fluoroscopy and should not
be done in very obese patients. It limits arteriography to the
ipsilateral leg, but provides a better platform for interventions if needed. Patients are typically placed in reverse with
the feet facing the head-end of the table, allowing maximum mobility of the image intensifier around the limbs.
The skin puncture is made at the top of the femoral head. A
less acute, less than 45-degree angle is usually required for
smooth insertion of the sheath and catheters. Long tapered
introducer-sheath instruments are sometimes needed. A
short 4- to 5-F sheath should be introduced first and a
cine angiogram performed to confirm access in the CFA,
and wire position in the superficial femoral artery (SFA)
before inserting the larger and longer sheaths and initiation of anticoagulation65 (Figure 20-6). An ipsilateral 30 to
50 degrees angulation will open up the superficial and deep
femoral artery (DFA) bifurcation. Anticoagulation can be
reversed at the end of the procedure for early removal of
sheath and to decrease the incidence of bleeding.
Brachial and Radial Approach
For radial artery (RA) and 5- to 6-F sheaths and for
brachial artery 5- to 7-F sheaths can be used. The biggest
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A
B
• FIGURE 20-6.
(A) Antegrade femoral artery access technique under direct
flouroscopy using micro puncture needle and wire. The wire is in the deep femoral artery.
(B) The wire is directed under flouroscopy into the superficial femoral artery.
advantage with these approaches is less bleeding and
early ambulation.66−68 There are however more ischemic
complications.69 These approaches require crossing the
great vessels of aorta and great care should be exercised
to avoid causing embolic strokes.
For BA approach, the arm is abducted and the puncture
is made at the site of maximum pulsation. Micropuncture
technique is recommended. When using this approach, one
should be aware of the need for longer length catheters if
angiography and intervention of the lower extremities is
anticipated. Left brachial approach has approximately 100
mm greater reach than the right brachial approach. Wholey
wire, glide wire, and other soft wires should be used with
these approaches to minimize trauma and spasm of the
vessels.
For RA approach,70 more skill is required. RA is superficial and lies against the bone. It has no major veins or
nerves in the vicinity. Its smaller size, however, limits the
use of some devices and larger stents. Hydrophilic sheaths
and guiding catheters of upto 6- to 7-F are now available
and can be used with this approach. They can accommodate most current balloons and stents. There is approximately a 3% incidence of RA occlusion postprocedure.
Allen’s test71 should be performed prior to cannulating RA
to confirm the ulnar artery patency (Figure 20-7). There is,
however, some controversy regarding the absolute value of
Allen’s test. The success rate of this approach is 95%.72 The
wrist is extended and the arm abducted in supine position.
Using micropuncture technique, puncture is made 1 to 2
cm proximal to the wrist crease. After sheath insertion,
the arm is brought back in the adducted neutral position.
Right arm is preferred to preserve left RA for future bypass
surgery if needed. Minimal local anesthesia is administered.
Five F long hydrophilic sheath is a good choice. Heparin
2500 to 5000 units should be given directly in the sheath.
Radial arteries are very prone to spasm and vasodilators
should be used. Nitroglycerin 100 to 200 mg and Verapamil 1 to 2 mg is directly given through the sheath. A
short cineangiogram should be performed to look for any
Radial artery
Ulnar artery
• FIGURE 20-7.
Atretic ulnar artery in a patient with
equivocal Allen’s test.
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anomalous arteries. One should look for radial recurrent
artery. The sheath should be removed immediately after the
procedure. Activated clotting time (ACT) check is not necessary. Compression straps, e.g., Hemoband (Hemoband
Corp., Portland, OR) are placed directly over the puncture
site. Pressure is maintained for approximately 90 minutes
for diagnostic and 180 minutes for interventional procedures. Access site complications are very uncommon.
Other Vascular Access Sites
PA is uncommonly accessed. The patient has to lie prone.
Puncture is performed under fluoroscopy and micropuncture technique is recommended. Axillary approach is more
popular among interventional radiologists. Left axillary
artery is preferred. The patient needs very close monitoring
for bleeding after axillary artery puncture because even a
medium-sized hematoma can cause nerve compression. BA
cut down is very uncommon now. It is used in less than 10%
of cases and should be performed only by experienced operators. Lumbar aortic punctures are again sometimes used
by radiologists in patients who have extensive PAD.73 Patient is placed prone. This site is only used as a last resort
because in case of bleeding complications direct pressure
cannot be applied and patient will likely require open surgical repair of the bleeding vessel.
Local Vascular Complications
Society for Cardiac Angiography and Interventions (SCAI)
has reported an incidence of 0.5% to 0.6% local vascular
complications. These complications comprise vessel thrombosis, dissection (Figure 20-8), bleeding, which can be
free hemorrhage, retroperitoneal bleeding, or access site
hematoma, arteriovenous fistula (Figure 20-9), distal embolization, or false aneurysm (pseudo aneurysm).
The operator should be well versed in the diagnosis and
management of these complications. Adequate specialty
care should be readily available at the facility where such
procedures are performed.
Thoracic Aorta and Aortic Arch Angiography
Noninvasive modalities like MRA and three-dimensional
CTA should be performed if available prior to invasive
imaging. Angiography provides 2D imaging and may underestimate the tortuosity of various vessels (Figure 20-10).
CTA and MRA will also provide information about the type
of aortic arch, and anomalous origin of any vessel from the
arch (Figure 20-11).
Thoracic Aorta
Commonly approached via right CFA utilizing 4- to 6-F
sheath and diagnostic catheters. Pigtail or tennis racquet
catheter is advanced over a soft J-tip guidewire under fluoroscopy. In cases of coarctation of the aorta, anteroposterior and lateral views are obtained with the contrast
• FIGURE 20-8.
Catheter-induced abdominal aortic
dissection.
injected proximal to the coarctation. For cases of patent
ductus arteriosus, selective aortic angiography is very sensitive in demonstrating small shunts and supercedes the sensitivity of right heart catheterization with stepwise oximetry. In cases of thoracic aortic aneurysms (TAA), MRA and
CTA are again very useful initial tools (Figure 20-12), but
catheter angiography is still considered essential to delineate the aneurysm and its relationship to the branches in
the chest and abdomen. If endovascular thoracic aneurysm
repair (ETAR) or open surgical repair is planned, then
coronary, brachiocephalic, visceral, and renal arteriography
should also be performed. For the diagnosis of thoracic
aneurysms, angiography is performed in the ascending thoracic aorta above the aortic valve using 30 to 40 mL of iodinated contrast at 15 to 20 mL/s using power injection. TAA
is less common than abdominal aortic aneurysm (AAA) but
the incidence is increasing as the median age of the population is also increasing. It also has a higher incidence of
rupture than AAA. Untreated, the mortality is greater than
70% within 5 years of diagnosis.74 Open surgical repair has
a mortality of 10% to 30%, spinal cord injury 5% to 15%,
respiratory failure 25% to 45%, myocardial infarction 7% to
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A
B
• FIGURE 20-9.
(A) Arteriovenous fistula between left CFA and vein. (B) Repair of
arteriovenous fistula with a covered stent.
20%, and renal dysfunction 8% to 30%.75 Chronic obstructive pulmonary disease (COPD) and renal failure are strong
predictors of rupture. In one series,76 the rupture rate was
high for aneurysms greater than 6 cm. In another series, no
rupture was reported in aneurysms less than 5 cm. Mean
size for rupture was 5.8 cm. With ETAR, the mortality and
the morbidity has been reported to be much less.77
In cases of thoracic aortic dissection, angiography has
a sensitivity of 80% and specificity of 95%. Noninvasive
modalities like CTA, MRA, and transesophageal echocardiography have taken over as the initial diagnostic tools;
however, cardiothoracic surgeons will still require an angiogram for additional information about coronary and
branch vessel involvement and the competence of the aortic valve prior to aortic repair. A pigtail or tennis racquet
catheter is advanced over a soft wire typically via the right
CFA approach. Most of the aortic tears are at the greater
(outer) curve and to avoid entry into the false lumen, the
catheter is used to direct the wire toward the inner curve.
Frequent contrast injections should be utilized to check the
catheter position. Entry into the false lumen is not uncommon and if that occurs, the catheter should be gently retracted and advanced into the true lumen.
radial approaches can be used in cases of suspected aortic
dissection and in patients with severe ileofemoral or abdominal aortic atherosclerotic disease. A pigtail catheter is
positioned above the sinus of valsalva and 40 to 60 mL of
nonionic iso-osmolar contrast at the rate of 20 cc/s is injected with a power injector. Both cine and DSA imaging
can be used. For a cine angiogram, 30 FPS and for DSA,
4 to 6 FPS are commonly used. LAO at 45 degrees angle
opens up the aortic arch and the great vessels in most cases.
DSA allows a lower contrast load of 30 mL injected at
20 cc/s.
Carotid and Cerebrovascular Angiography
Catheter angiography is the gold standard for aortic arch,
cervical, and cerebral angiography. A major drawback for
angiography in this territory has been the risk of strokes.
There was 1.2% incidence of stroke in the hands of radiologists in the ACAS78 trial. In a later study79 performed
by cardiologists, the risk was 0.5%. Proper patient selection
and the procedural volumes and the technical skill of the
operator are important predictors of this risk.
Carotid Artery
Aortic Arch
Catheter angiography is still considered the gold standard,
but 3D CTA and MRA are excellent for imaging the aortic
arch and should be considered prior to considering arch angiography. CFA is the most common access site. Brachial or
Many patients with carotid artery disease are asymptomatic. History and physical examination are therefore not
very sensitive in detecting carotid artery disease. Carotid
duplex ultrasound, CTA, and MRA should be utilized as the
initial diagnostic tools (Figure 20-13). Invasive angiography
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• FIGURE 20-11.
CTA showing extremely tortuous carotid
arteries making endovascular intervention an undesirable
option in such cases.
CTA nicely showing a “bovine” aortic
arch. There is also severe stenosis of the left internal carotid
artery and the aortic arch is also “type 3” making carotid artery
stenting an unsuitable option in this case.
Courtesy: Robert Falk MD, 3-DR Louisville, KY.
Courtesy: Robert Falk MD, 3-DR Louisville, KY.
• FIGURE 20-10.
remains the gold standard in patients considered for carotid
artery stenting (CAS). The landmark North American
Symptomatic Carotid Endarterectomy Trial (NASCET),
European Carotid Artery Surgery (ECAS), and Asymptomatic Carotid Artery Stenosis (ACAS)78,80,81 trials were
all based on angiography.
Brachiocephalic (BC) artery arises as the first great vessel
from the aortic arch and divides into right subclavian (RSC)
and right common carotid arteries (RCCA). RCCA almost
always arises from the BC and rarely as a separate branch
from the aorta. It may come from a single common carotid
trunk that also gives rise to left common carotid artery
(LCCA). RCCA further divides into right internal carotid
artery (RICA) and right external carotid artery (RECA)
at the fourth cervical vertebra. The angle of the mandible
is a good bony landmark for the bifurcation of the CCA.
ECA gives numerous branches (Figure 20-10). LCCA arises
75% of the time as a separate branch from aorta, 10% to
15% of the time as a common origin with the BC, and approximately 10% of the times from the BC (bovine origin)
(Figure 20-11). ICA can be divided into four segments82
(Figure 20-11).
a. Prepetrous (cervical). Between the CCA bifurcation and
the petrous bone. This segment does not give rise to any
• FIGURE 20-12.
CTA showing thoracic aortic aneurysm.
Courtesy: Robert Falk MD, 3-DR Louisville, KY.
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• FIGURE 20-14.
• FIGURE 20-13.
CTA of carotid arteries showing patent
stent in the right common and internal carotid arteries (arrows).
Courtesy: Robert Falk MD, 3-DR Louisville, KY.
major branches and is the most common site of carotid
stenosis involving the ostial and the proximal portion of
the artery.
b. Petrous. This segment courses through the petrous bone
and makes a 90-degree L-shaped angle on angiogram.
c. Cavernous. This is the part through the cavernous sinus.
d. Supraclinoid. This segment gives ophthalmic, posterior
communicating, and anterior choroidal branches before
terminating as the middle and anterior cerebral arteries.
Ophthalmic artery supplies the ipsilateral retina and optic nerve and is a source of important collateral route between ICA and ECA. Posterior communicating branch
connects ICA with posterior cerebral artery to provide
communication between the anterior and posterior circulation. The area supplied by ACA and MCA is referred
to as “carotid territory of the brain.”
Angiography
Angiography is considered to be the gold standard for
the diagnosis of extracranial and intracranial carotid artery
disease. For complete cerebrovascular circulation, carotid
angiography should be done in conjunction with aortic
arch and selective vertebral angiography. Knowledge of
arch anatomy and presence of proximal AS and tortuosity are crucial in the appropriate selection of the catheters
for selective angiography. For Type-I or Type-II arch, 5 F
JR4, Davis, HH (Meditech Watertown, MA), or Berenstein catheters are adequate. In patients with bovine arch
Vitek catheter is often needed. For Type-III arch (elon-
Venous phase of cerebral angiogram.
gated), reverse curve catheters like Simmons (Angiodynamics, Queensbury, NY) or Vitek are often required. Simmons catheter can be very useful as it “travels up” the
carotid artery and does not get dislodged. Its use, however,
requires more skill.
Meticulous technique and double flushing is recommended once the catheter is beyond the aortic arch. Diluted low- or iso-osmolar contrast is injected at 4 to 6 mL/s
for a total of 8 mL for CCA angiography using DSA at 4 to
6 FPS.
Cerebral circulation imaging should be continued into
the venous phase to rule out any venous anomaly (Figure
20-14). Multiple projections and angulation are sometimes
needed for optimal visualization. In most cases, a straight
AP and lateral or 30 to 40 degrees ipsilateral angle will
open up the bifurcation to assess the lesion (Figures 2015 and 20-16). RAO projection opens up the bifurcation
of the BC artery. In patients who are undergoing carotid or
vertebral interventions, cerebral angiography should be performed before and after the intervention, for comparison,
in the event of suspected embolic stroke. It also provides information about intracranial aneurysms and atherosclerotic
disease. A straight PA cranial view to bring the petrous bone
at the base of the orbit (Towne’s view) will nicely outline
the cerebral circulation in most cases (Figure 20-17).
For assessment of the severity of carotid stenosis, the
methodology used by NASCET investigators is most popular. This method compares the stenotic area with the most
normal appearing artery distal to the stenosis.
Vertebral Artery
Left vertebral artery originates as the first branch of subclavian artery. In 3% to 5% of cases, it may arise directly
from the aorta between LCCA and LSCA. Very rarely, it
may originate distal to LSCA. Right vertebral artery can
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• FIGURE 20-16.
Severe right carotid artery stenosis in a
patient with previous carotid endarterectomy.
Courtesy: John Laird MD, Washington Hospital Center, Washington,
DC.
• FIGURE 20-15.
Severe stenosis of right internal carotid
artery.
A
B
• FIGURE 20-17.
(Towne’s view).
(A) Right and (B) and lateral view of cerebral angiography in AP
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Angiography
• FIGURE 20-18.
Subclavian and vertebral artery angiography is commonly
performed from the CFA approach. For patients with severe lower extremity PAD with no femoral access or who
have Type-III aortic arch ipsilateral brachial approach can
also be used. Unfractionated heparin (3000–5000 units)
are given when using the brachial approach. RA can also
be used for angiography and in addition to heparin vasodilators should also be given with this approach. AP, RAO, and
LAO projections will open up the SCA and VA. RAO cranial angle will show the origin of internal memory artery
(IMA). JR4 catheter is usually adequate for straight aortic arch. For elongated aortic arch, Vitek, Head Hunter,
or Simmons 1 or 2 are used (Figure 20-19). For vertebral
artery, 3 to 4 mL/s for a total of 6 mL of contrast is generally sufficient. Nonselective angiography with a blood pressure cuff inflated on the ipsilateral arm will improve the
visualization of ostial disease. Ostia are also better seen in
the contralateral oblique projections and V2 and V3 segments are better seen in PA and lateral views or ipsilateral oblique views. Intracranial segments are best seen in
steep 40 degrees PA cranial (Towne’s) view and crosstable
view.
CTA showing “Circle of Willis.”
Courtesy: Robert Falk MD, 3-DR Louisville, KY.
originate from RCCA and duplication of vertebrals can occur at any level. It originates from the superior and posterior
aspect of the RSCA. The two vertebrals converge to form
the basilar artery at the base of the pons (Figure 20-18).
It can be divided into four segments83 :
V-1: From the origin to the transverse foramen of the
fifth and sixth cervical vertebrae.
V-2: Its course within the vertebra until it exits at C2
level.
V-3: Extracranial course between the transverse foramen of C2 and base of skull where it enters foramen magnum.
V-4: Intracranial course as it pierces the dura and arachnoid maters at the base of skull and ends as it meets
the opposite vertebral artery (Figure 20-14).
Intracranial part gives anterior and posterior spinal
branches; penetrating branches and posterior inferior cerebellar artery (PICA), which gives supply to dorsal medulla
and cerebellum. Left vertebral artery is usually dominant
and stenosis of the dominant vertebral is likely to cause
symptoms.
AS is the dominant pathology involving the ostium and
proximal extracranial segment of the VA. Surgical revascularization carries significant mortality and morbidity approaching 20%.84 With rapidly improving skills and technology, endovascular revascularization is becoming a very
attractive option for these patients.
2
4
1
• FIGURE 20-19.
3
Selective angiography of left subclavian
artery (1) using a Simmons catheter. (2) A normal left
vertebral artery, (3) a small internal mammary artery, and
(4) thyrocervical trunk are also seen.
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• FIGURE 20-20.
CTA of brachial, radial, and ulnar
arteries.
Courtesy: Robert Falk MD, 3-DR Louisville, KY.
Subclavian, Brachiocephalic,
and Upper Extremity
This vascular bed constitutes approximately 15% of symptomatic extracranial cerebrovascular disease. Right subclavian artery (RSCA) arises from BCA on the right and LSCA
is the last major branch from the aorta on the left. In 0.5%
population, RSCA arises as the terminal branch from the
descending thoracic aorta and courses over to the right toward its normal distribution to the right upper extremity. Rarely, RSCA and RCCA may have separate origins
from the aorta instead of a BCA. It gives vertebral, IMA,
and thyrocervical trunk (TCT) from its first segment. TCT
gives inferior thyroid, suprascapular, and transverse cervical
branches. SCA becomes axillary artery at the lateral margin of the first rib that in turn becomes BA at the anatomic
neck of the humerus. Opposite to the neck of radius, BA
divides into ulnar and radial arteries (Figure 20-20). In approximately 1.3% of cases, RA originates from the axillary
artery and in 15% to 20% of cases from the upper BA. Ulnar
artery helps to form the superficial palmar arch and the RA
the deep palmar arch (Figure 20-21).
Angiography
Angiography is generally needed in patients presenting with
arm claudication, and in other causes of arm ischemia, e.g.,
blue digit syndrome, severe digital ischemia, and blunt and
penetrating trauma with vascular injury to these vessels.
CTA and MRA are useful to delineate arch anatomy. Step-
• FIGURE 20-21.
CTA of hand arteries.
Courtesy: Robert Falk MD, 3-DR Louisville, KY.
wise angiography with iso-osmolar contrast is preferred.
Contrast of 5 to 10 mL with hand injection using DSA
will give good visualization of these vessels. JR4 catheter
is routinely used (Figures 20-22 and 20-23). Vitek or Simmons catheter maybe required depending on the take off of
SCA or BCA. Vitek catheter is advanced under fluoroscopy
and positioned in the descending thoracic aorta with the
curve facing the right side of the arch and the tip facing
north. Catheter is gently advanced and each great vessel
is selectively engaged. After completion of the angiogram,
the catheter is removed over a wire. Simmons catheter is
reshaped in the ascending thoracic aorta and is gently withdrawn to engage each vessel selectively. It is also removed
after straightening with a wire.
Orthogonal oblique views will visualize SCA and its
branches. LAO for RSCA and RAO for LSCA will give
good views of these vessels (Figures 20-24 and 20-25). Patient’s arm should be adducted to the neutral position during angiography. For axillary artery and BA angiography,
catheter is advanced into distal SCA. Usually a long 300 cm
Wholey, Magic Torque or a Stiff Shaft Angled Glide wire is
used to exchange the JR4, Vitek, or Simmons catheter for a
straight 4- to 5-F Glide catheter or a multipurpose catheter.
Axillary artery is angiographed in adducted arm position
and BA in an abducted position with forearm supine. For
the forearm and hand angiogram, the diagnostic catheter
is further advanced into the distal BA. Forearm should be
supine, fingers splayed and thumb abducted. PA projection
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5 F JR4
100% occluded left
subclavian artery
6 F long shuttle sheath
• FIGURE 20-22.
Hundred percent occluded left
subclavian artery. Dual injection technique is demonstrated with
5-F JR4 catheter in the subclavian artery and 6-F long shuttle
sheath in the ascending aorta.
Courtesy: John Laird MD, Washington Hospital Center, Washington,
DC.
• FIGURE 20-24.
Critical stenosis of the origin of
innonimate artery seen on angiogram performed via right radial
artery. Aortic arch is not clearly opacified due to the stenosis.
Right common carotid artery is patent (arrow head).
Courtesy: John Laird MD, Washington Hospital Center, Washington,
DC.
is adequate. Vasodilators are given intraarterially due to the
spasmodic nature of these arteries. For borderline lesions a
translesional gradient can be measured using a 0.014-inch
pressure wire or simultaneous measurement of pressure between 4- and 5-F catheter tip placed distal to the lesion and
the side port of a long 6-F sheath positioned in the distal
aorta. Vasodilators can be used to augment the gradient. A
gradient greater than or equal to 15 mm Hg in SCA and
BCA is considered significant.
Abdominal Aorta
• FIGURE 20-23.
Left subclavian artery widely patent
after stenting.
Courtesy: John Laird MD, Washington Hospital Center, Washington,
DC.
Atherosclerotic disease is very common with more involvement of the infrarenal abdominal aorta. Abdominal aorta
starts at the level of the diaphragm (T12) and continues
anterior to the spine and to the left of inferior vena cava. It
bifurcates at L4 level into the right and left common iliac
artery.85 AA is 15 to 25 mm in diameter and larger in males
and older populations.86 It gives rise to the celiac trunk at
T12–L1, superior mesenteric artery (SMA) at L1–L2, and
inferior mesenteric artery (IMA) at L3–L4 level. Renal arteries originate posterolaterally at L1–L2 level below the
origin of the SMA. Four pairs of lumbar arteries originate
below the renals.
Abdominal aorta is considered to be aneurysmal when
the anteroposterior diameter is 3 cm. Diagnosis is based
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• FIGURE 20-25.
Innonimate artery is widely patent after
stenting with opacification of aortic arch.
Courtesy: John Laird MD, Washington Hospital Center, Washington,
DC.
on formulas that adjust for age or body surface area or by
calculating the ratio between the normal and dilated aortic
segments.87−90 The prevalence of AAA increases with age.
In a necropsy study,91 incidence was 5.9% in men aged 80
to 85 years and 4.5% in women who were older than 90
years of age. Based on U.S. studies, the prevalence for AAA
2.9 to 4.9 cm is 1.3% for men aged 45 to 54 years and up to
12.5% for men aged 75 to 84 years. Comparable prevalence
for women is 0% to 5.2%.
Common iliac artery aneurysms are usually also found in
association with AAA. One-third to one-half are bilateral
and 50% to 85% are asymptomatic when diagnosed.92,93
Rupture occurs when they are more than 5 cm.
For the diagnosis, a history of abdominal and back pain
and presence of a pulsatile mass are important indicators
of the presence of AAA. Plain X-ray film of the abdomen
may show curvilinear aortic wall calcification as an incidental finding. US or nuclear scan of abdomen may show AAA
as an incidental finding. Similarly, during unrelated arteriography, slow or turbulent flow in the aorta may suggest
presence of AAA.
US has a specificity of nearly 100% and sensitivity of 92%
to 99% for the diagnosis of infrarenal AAA.87 For suprarenal
AAA, the accuracy is much less. CTA and MRA are the
• FIGURE 20-26.
CTA of abdominal aorta and iliac
arteries showing infrarenal abdominal aortic aneurysm and
accessory bilateral renal arteries.
Courtesy: Robert Falk MD, 3-DR Louisville, KY.
current gold standard for the diagnosis of AAA.94 Spiral
contrast-enhanced CTA with 3D reconstruction is now the
standard preop evaluation to look for vessel calcification,
thrombus, and anatomy of the aneurysm for optimal stent
graft placement (Figure 20-26). In addition to previously
described limitations, CTA tends to overestimate the diameter of the neck and underestimate the length of the
neck of the aneurysm. MRA is inferior to spiral contrastenhanced CTA in spatial resolution and not very good for
detecting vessel wall calcification. MRA is slower than CTA
but not inferior in the diagnosis. It is considered superior
to catheter angiography for defining the proximal extent of
the AAA, venous anatomy, intraluminal thrombus and iliac
aneurysms.95 Renal arteries can also be imaged accurately
with the new scanners. Standard MRA protocols for AAA
are not available everywhere.
Catheter angiography is always done at the time of endovascular aneurysm repair (EVAR). Pelvic angiography
is also done at the same time to visualize iliac arteries,
which are also frequently involved with abdominal aortic
aneurysm. It also helps in the optimal visualization of collateral or variant arterial anatomy.96,97 Contrast angiography, however, is not accurate in estimating the diameter
of the AAA due to presence of thrombus that is usually
present in the aneurysms. CTA or MRA are thus needed
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• FIGURE 20-27.
Large abdominal aortic aneurysm
(arrows), only partially visualized on contrast angiogram. The
rest of the sac is filled with thrombus.
in conjunction prior to EVAR (Figures 20-27 and 20-28).
Prior to open or endovascular repair the maximum transverse diameter of the aneurysm, its relationship to the renal arteries, presence of iliac artery or hypogastric artery
aneurysm, stenosis of renal or iliac arteries, and presence
of horse-shoe kidneys, etc., must be defined. The diagnostic modality must provide measurement of the neck and
body of the AAA and of the iliac arteries. CTA is also excellent in defining the type of endoleak after EVAR before
angiography to repair the endoleak (Figure 20-29).
Femoral approach is most common using 4- to 6-F pigtail or Omniflush catheter. Radial, brachial, or axillary approaches are also used. As a last resort, translumbar puncture can be done. For AAA, the pigtail or Omniflush
catheter is positioned such that the tip is at T12-L1 level
so that the side holes are at L1-L2 level. Contrast of 30 to
50 cc is injected. For abdominal or thoracic aortic stenosis, a translesional gradient can be measured as previously
described. A gradient greater than 10 mm Hg is considered
significant (Figure 20-17).
Visceral Artery Aneurysms
Open or endovascular repair has a class I indication for
aneurysms greater than 2 cm in women of child-bearing age
or in men or women undergoing liver transplant. They have
Class IIa indication in men or in women who are beyond
the child-bearing age. Splenic and hepatic artery aneurysms
are not very common.98,99 Most are found incidentally during imaging for other reasons. Most are asymptomatic but
a rupture in pregnant women carries a very high mortality
that may approach 70% for the mother and >90% for the
• FIGURE 20-28.
CTA of an abdominal aortic aneurysm
showing a large thrombus in the aneurysm not likely to be
visible on a catheter angiogram.
Courtesy: Robert Falk MD, 3-DR Louisville, KY.
fetus.100 In general population the rupture carries a mortality of 10% to 25%
SMA has 6% to 7% of all visceral aneurysms. Lower extremity aneurysms generally do not rupture but pose a danger of thromboembolism or vessel thrombosis. PA carries
up to 70% of all LE aneurysms. CTA and MRA are the tests
of choice.
Renal Artery
Renal artery stenosis (RAS) is a very common and progressive disease in patients with PAD. It is a relatively uncommon cause of hypertension.101−103 A duplex US study of
patients older than 65 years showed an incidence of 9.1%
in men, 5.5% in women, 6.9% in white population, and
6.7% in black population.102 In another series of 395 patients with abdominal aortic and ileofemoral disease, the
incidence of RAS greater than 50% was 33% to 50%.104
The incidence of significant RAS in patients who were undergoing coronary angiography who also underwent renal
angiography was approximately 11% to 18%.105−107 Conversely, the incidence of clinically significant CAD was 58%
in patients with atherosclerotic RAS.108 In 24% patients
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• FIGURE 20-30.
(A and B) MRA of renal and mesenteric
arteries showing normal vessels and abdominal aorta.
Courtesy: Robert Falk MD, 3-DR Louisville, KY.
Angiography
• FIGURE 20-29.
CTA of an abdominal aortic endograft
showing an endoleak via a collateral between Internal iliac and
inferior mesenteric arteries (arrow).
Courtesy: Robert Falk MD, 3-DR Louisville, KY.
with end-stage renal disease (ESRD) and in need for dialysis, there was severe atherosclerotic RAS.109 AS is by far the
most common pathophysiological mechanism approaching
90% in patients with RAS. Fibromuscular dysplasia is found
in approximately 10% of patients with RAS. There is also
significant progression of RAS. In patients with less than
60% RAS, progression was 20% per year and in those with
greater than 60% stenosis, there was complete occlusion
in 5% cases at 1 year and 11% at 2 years.110−112 Bilateral RAS is also common. In six different studies including
319 patients, it was found in 44% of cases.113 renal atrophy and ESRD can develop in patients with RAS and RA
occlusion.114−116
Renal arteries arise at L1–L2 level from the posterolateral aspect of the abdominal aorta. Right RA typically originates slightly higher than the left. Accessory renal arteries
are also quite common and found in 25% to 35% of the
general population. These usually supply the lower poles
of the kidneys. They can arise anywhere from suprarenal
aorta down to the iliac and are generally smaller in caliber.
Main renal artery further branch into segmental, interlobar,
arcuate, interlobular, and arterioles.
MRA has an ACC/AHA Class I indication as a screening
tool for RAS (Figure 20-30). Similarly, CTA has Class I
indication in patients with normal renal function. When the
clinical suspicion is high and when the noninvasive tests are
inconclusive, catheter angiography has Class 1 indication
for the diagnosis of RAS (Figure 20-18).
MRA with gadolinium compared to catheter angiography has a sensitivity 90% to 100% and specificity of 76% to
94% in atherosclerotic RAS. For patients who have FMD,
the accuracy of MRA is less.117 MRA is the most expensive test diagnostic tool and other limitations are as discussed before. CTA has a sensitivity of 92% and specificity
of 95% when compared to DSA.118 Use of CTA is limited
because of a risk of CIN. CTA with the old scanners had
a sensitivity of 59% to 96% and specificity of 82% to 99%
when compared to catheter angiography.119−124 With the
new scanners, they have improved to 91% to 92% and 99%,
respectively.
Currently, catheter angiography is reserved for those patients whose diagnosis is not clear by noninvasive testing. It
is also recommended in patients who are undergoing coronary or peripheral angiography in whom there is a high
suspicion of RAS.
For contrast angiography, CFA approach is most common using 5- to 6-F short sheath. In severely tortuous ileofemoral vessels, a long 6 F sheath should be used. Brachial
approach is used in patients with poor femoral approach
or if the renal arteries are acutely downward angulated.
Nonselective angiography is done first with a pigtail or
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• FIGURE 20-31.
Bilateral renal artery stenoses on flush
angiography of abdominal aorta utilizing pigtail catheter.
Omniflush catheter positioned at L1-L2 level in AP view
to look for ostia of the renal arteries and also to look for
accessory renal arteries. DSA at 4 FPS with 30 mL nonionic iso-osmolar contrast at the rate of 15 mL/s is usually
injected (Figure 20-31). For selective renal angiography 4 to
• FIGURE 20-32.
Selective left renal artery angiography
utilizing Judkin’s right coronary catheter showing significant
stenosis.
• FIGURE 20-33.
Selective right renal artery angiography
utilizing Cobra catheter.
5 F JR4, renal double curve, Cobra, IMA, SOS, or Hockey
stick catheters can be used (Figures 20-32 to 20-34). For
downward-angulated renals, reverse curve catheters, for example, Simmons or Omniselective can be utilized from
the femoral approach or a straight MP catheter from the
brachial approach. Contrast of 5 to 8 mL at 5 mL/s using DSA at 4 FPS will give excellent images. Usually an
ipsilateral 15 to 30 degree oblique view will display the ostium and proximal renal artery. Another useful technique
is to modify the LAO/RAO angulation under fluoroscopy
while the catheter is engaged until the tip of the diagnostic
• FIGURE 20-34.
Selective right renal artery angiography
showing in-stent restenosis utilizing Judkin’s right coronary
catheter.
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catheter is maximally opened. Cranial and caudal angulation can be used to open up the bifurcation lesions. Cineangiogram is prolonged until the nephrogram phase to assess
the kidney size and regional perfusion of the kidney to optimize revascularization strategy.
2
No Touch Technique
Abdominal aorta frequently is severely atherosclerotic and
there is risk of visceral or distal embolization of atheroma
during manipulation of catheters. With this technique, a
0.14-inch wire is advanced through the catheter beyond the
renal arteries. The catheter is manipulated toward the renal
ostia without touching them, thus avoiding the scraping of
the aortic intima.
In borderline lesions, a translesional gradient should be
measured. A 0.014-inch pressure wire is most accurate. Alternatively, a 4 F diagnostic catheter is advanced beyond the
lesion and gradient measured between the catheter and a
6 F sheath in the aorta. A systolic gradient greater than or
equal to 20 mm Hg or a mean gradient of 10 mm Hg is considered significant. Vasodilators, for example, nitroglycerin
100 to 300 mg or Papaverine 20 to 30 mg intravenously
can be used to augment the gradient. Intravascular ultrasound (IVUS) is also a very useful imaging modality in renal arteries to accurately assess the artery size and disease
involvement of the ostia.
CIN is a significant risk and can be as high as 20%
to 50% in patients with both chronic kidney disease and
diabetes mellitus.125,126 Iso-osmolar contrast agent Iodixinol showed less nephrotoxicity than low-osmolar agent
Iohexol in one randomized trial.127 In patients with creatinine clearance less than 60 mL/min and serum creatinine
greater than 1.2 mg/dL, Mucomyst 600 mg twice a day decreased the incidence of CIN in patients undergoing coronary angiography.128 In patients with renal insufficiency,
CO2 angiography can be done injecting 40 to 50 mL of
CO2 delivered by hand injection while the patient is holding breath using DSA. This will allow visualization of renal
ostia to facilitate selective renal angiography. Gadolinium
contrast or iodinated contrast in a 50:50 ratio with normal
saline can also be used in patients with renal dysfunction.
Mesenteric Arteries
AS involvement of these arteries is common but mesenteric ischemia is uncommon. Mesenteric ischemia can also
be caused by nonobstructive arterial disease in cases of low
flow states. Two-thirds of the patients with intestinal ischemia are women with a mean age of 70 years and most
have preexisting CAD.129−131 Postprandial abdominal pain
is almost always present as a symptom.
Celiac artery arises from the anterior surface of the aorta
at T12 level. It travels inferiority for 1 to 3 cm before dividing into common hepatic, splenic, and left gastric arteries.
SMA arises at the L1–L2 level and gives rise to middle colic
and pancreatoduodenal arteries. IMA arises at L3–L4 level
and gives rise to left colic and superior rectal arteries (Figure
20-35).
1
4
3
• FIGURE 20-35.
Mesenteric vessel arteriogram showing
(1) patent spenic, (2) common hepatic, (3) superior mesenteric,
(4) and right renal arteries. Left renal artery is absent.
These vessels have rich collateral pathways. meandering mesenteric artery allows communication between SMA
and IMA. Pancreatoduodenal artery communicates between celiac artery and SMA while IMA has collateral communications with the EIA. Occlusion of one of these arteries generally does not cause intestinal ischemia. Classical
teaching was that severe stenosis or occlusion of two of the
three of these arteries has to be present to cause this syndrome, but this is not considered entirely true now.132,133
Single vessel disease, virtually always of the SMA, can cause
intestinal ischemia (Figure 20-36). Patients in whom collateral circulation has been interrupted by prior surgery are
especially prone to intestinal ischemia by single vessel involvement.
Duplex ultrasound, CTA, MRA with gadolinium enhancement, and catheter angiography with lateral abdominal aortography where noninvasive testing is not available
or indeterminate, all have Class I indication in the diagnosis. In many cases, US is not very helpful because of the
presence of bowel gas or patient body habitus. CTA and
MRA are good for detecting proximal artery lesions. CTA,
however, requires intravenous contrast. In case of acute intestinal ischemia, catheter angiography is the best test but
it is limited by the time it may require in such emergencies.
It can differentiate between occlusive versus nonocclusive
disease. Sometimes the patient is not stable to undergo the
procedure. Immediate laparotomy and surgical revascularization is the best approach in such cases.
Chronic intestinal ischemia is rare and almost always
caused by AS.134 Buerger’s disease, FMD, and aortic dissection are very rare causes.
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1
2
• FIGURE 20-36.
Angiogram in a lateral projection
showing critical stenosis of (1) celiac trunk and (2) 100%
occlusion of SMA in a patient with severe mesenteric angina.
• FIGURE 20-37.
Selective angiography of celiac trunk
utilizing reverse curve Simmons catheter.
Courtesy: John Laird MD, Washington Hospital Center, Washington,
DC.
Catheter angiography has ACC/AHA Class I indication
in patients with suspected nonocclusive intestinal ischemia
whose condition does not improve rapidly with the treatment of the underlying disease, e.g., circulatory shock. It
can also confirm vasospasm and vasodilator agents can be
administered.135−137
CFA approach is most commonly used. Arm approach
can be used if femoral approach is not feasible. A 4 to 5
F pigtail or Omniflush catheter is placed at T12-L1 level
and 30–40 cc of contrast injected via power injector using
DSA at 15 cc/s at 4 to 6 FPS. Lateral view will best visualize
these vessels (Figures 20-37 and 20-38). An AP view should
also be done to visualize the mesenteric circulation and
the presence of any collateral vessels. “Arc of Riolan” (an
enlarged collateral vessel connecting the left colic branch
of the IMA with SMA) is an angiographic sign of proximal
mesenteric arterial obstruction that is visible on the AP
view.
Pelvis and Lower Extremity
Infra renal aorta and ileofemoral vessels are amongst the
most commonly involved in atherosclerotic PAD. Ileofemoral involvement is more common in patents that
have history of hypertension and smoking while below the
knee, disease is commoner in diabetic population. Surgical
• FIGURE 20-38.
Selective angiography of superior
mesenteric artery utilizing reverse curve Simmons catheter.
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revascularization in the ileofemoral region has a patency
of >80%138−140 but it is associated with significant mortality and morbidity. Endovascular revascularization is rapidly
taking over as the first line of treatment in these cases.
AA bifurcates into common iliac arteries (CIA) at the
L4-L5 level. CIA divides at L5-S1 junction into internal iliac artery (IIA) and external iliac artery (EIA). IIA courses
posteromedially and EIA anterolaterally and exits the pelvis
posterior to the inguinal ligament to become the CFA. The
IMA takes off medially at the junction of EIA and CFA.
The deep iliac circumflex artery takes off laterally and superiorly. CFA originates at the inguinal ligament and bifurcates at the lower part of the head of the femur into SFA
anteromedially and DFA posterolaterally. DFA has two major branches, lateral and medial circumflex femoral arteries.
These arteries along with the first perforating branch connect with the IIA via the superior and inferior gluteal and
obturator arteries. Distally, its branches provide collaterals
to the network around the knee, thus communicating with
the popliteal and tibial vessels. Therefore, in cases of occlusion of SFA, the DFA becomes a very important source of
collateral circulation.
The SFA becomes the popliteal artery (PA) as it enters the adductor canal (Hunters canal). PA runs posterior
to the femur and gives sural and geniculate branches. Below
the knee, the PA divides into anterior tibial artery (AT) that
runs anterior and lateral to the tibia and continues into the
dorsum of the foot as the dorsalis pedis artery (DP). After
the takeoff of the AT, the PA continues as the tibioproneal
trunk (TPT) that divides into posterior tibial and peroneal
arteries. The peroneal artery runs between the AT and PT.
It joins the PT above the ankle via its posterior division and
the AT via its anterior division. PT runs behind the medial
malleolus and gives medial and lateral plantar branches. The
lateral plantar and distal DP joins to form the plantar arch.
• FIGURE 20-39.
CTA of abdominal aorta and pelvic
arteries showing severe calcification of distal aorta, common
and internal iliac arteries. Celiac trunk, superior mesenteric,
and renal and inferior mesenteric arteries are patent.
Courtesy: Robert Falk MD, 3-DR Louisville, KY.
Angiography
CTA and MRA are very good tools to delineate the anatomy
(Figures 20-39 to 20-41). Compared to DSA, the MRA has
shown a sensitivity of 97% and specificity of 99.2%.141 Interest in this technology is growing as the sole diagnostic
tool prior to surgical revascularization.142 MRA in fact can
be a better imaging modality than CTA and catheter angiography for below the knee vasculature (Figure 20-42).
CTA is also excellent in the diagnosis but limited by CIN
and radiation hazard.143
Contrast angiography is considered to be the gold standard (Figures 20-43 to 20-45). It should be reserved for the
patients being considered for revascularization and should
not be done for diagnostic purposes only if CTA or MRA facility is available. Initially a nonselective angiogram should
be done. CFA, brachial, or radial approaches are used.
Sheaths and catheters of 4 to 6 F are used. A PT or OF
catheter is positioned at L4–L5 and 30 mL of contrast at 15
mL/s is injected with a power injector. DSA at 4 to 6 FPS
should be utilized. In cases of known iliac artery obstruction, the catheter should be placed just below the renal
• FIGURE 20-40.
CTA showing aortobifemoral and left
femoral–distal bypass graft.
Courtesy: Robert Falk MD, 3-DR Louisville, KY.
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A
B
• FIGURE 20-41.
“Thick maximal intensity projection” CTA of (A and B) left lower
extremity arterial circulation and (C) bilateral ileo femoral arteries.
Courtesy: Robert Falk MD, 3-DR Louisville, KY.
arteries to look for collaterals from the lumbar branches.
Selective iliac angiogram is typically done from the contralateral side using 4 to 5 F IMA or JR4 catheter. Other
catheters, e.g., Simmons, Omniflush, or SOS, can be used
as needed. An exchange length of 200 to 360 cm angled
glide wire is advanced under flouro into the CFA or more
distally and the catheter exchanged for a straight 4 to 5 F
glide or MP catheter. A selective stepwise angiogram of the
leg is performed. A 10 to 15 cc contrast is used at each
step. For optimal below the knee angiogram, the catheter
should be advanced to the distal SFA and vasodilators used.
Interactive bolus chase technique as described before can
also be used for nonselective angiography of both the legs.
• FIGURE 20-42.
MRA of below the knee arteries showing
100% occlusion of right posterior tibial artery (solid arrow) and
100% occlusion of all three arteries on the left (dashed arrows).
Courtesy: Robert Falk MD, 3-DR Louisville, KY.
• FIGURE 20-43.
Arteriogram of aorto bifemoral graft with
the sheath inserted into the right limb of the graft (arrow).
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1
2
• FIGURE 20-44.
(1) Hundred percent occlusion of left
superficial femoral artery. (2) Collateral vessels reconstituting
popliteal artery.
Another technique to engage the common iliac artery
is to advance the angled glide wire in the catheter (usually pig tail) already in the abdominal aorta that was used
for initial angiogram. The tip of the catheter is faced toward the contralateral iliac. The wire is advanced to “open
up” the catheter and the catheter gently pulled down toward the aortic bifurcation. The glide wire will drop down
into the common iliac artery as the catheter hooks the ostium of the common iliac. The catheter is then exchanged
for the straight catheter as described above. This technique
saves an extra step of engaging the contralateral iliac with
another catheter first.
After the angiogram of the contra lateral leg is completed, the catheter is pulled just a few inches proximal
to the tip of the insertion sheath in the ipsilateral leg and
angiogram completed in a stepwise fashion. This can also
be done with the sheath alone but a smaller catheter has
less risk of causing dissection during angiography. Power
injector, hand injection, or an “assist device” can be used.
Contralateral angle of 30 to 40 degrees will open up the
iliac artery bifurcation and 30 to 40 degrees ipsilateral angles will open up the vessels below the EIA. Lesions with
greater the 50% diameter stenosis and translesional systolic
gradient greater than 10 mm Hg are considered significant.
If femoral approach is not feasible, then a brachial or radial
approach utilizing straight catheters can also be used for selective angiography of each leg. Vasodilators, for example,
NTG 100 to 300 mg, Papavarin 30 to 60 mg, or Tolazoline 12.5 to 25 mg can be used to optimize below the knee
imaging and also to augment translesional radiant.144
• FIGURE 20-45.
Hundred percent occlusion of right SFA
with extensive collateral vessels from deep femoral artery
connecting with the popliteal artery in the same patient. This
“mirror imaging” of AS frequently seen in the thigh vessels.
High success rate with endovascular treatment has now
encouraged most experienced operators to tackle below the
knee PAD that was long thought to be only fit for surgical
therapy. Patients with CLI who are being subjected to amputation should be given an option for peripheral vascular
intervention even if it helps in the short-term healing of
their infections and to prevent more proximal amputation.
•
VENOUS CIRCULATION
With improvement in technology, enthusiasm is gaining
momentum in the endovascular treatment of venous occlusive disease (VOD). The most common causes of VOD
are coagulopathies, extrinsic compression from tumors, and
thrombosis from iatrogenic catheters and wires. Venous enhanced subtracted peak arterial (VESPA) magnetic resonance venography is comparable to conventional venography in the diagnosis of femoral and iliac deep venous
thrombosis.145 CTA and MRA are both useful in the diagnosis of upper extremity and central VOD, stenoses, extrinsic masses, and pulmonary embolism.
Venous system parallels arterial system. The superficial
veins in the infrainguinal region drain into the small saphenous vein, which drains into the popliteal vein, and into
the greater saphenous vein that drains into the common
femoral vein (CFV). The deep veins converge on the CFV
that continues as the external iliac vein and combines with
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the internal iliac vein to form the common iliac veins which
drain into the IVC that further drains into the right atrium
of the heart.
Superficial upper extremity veins drain into the lateral
cephalic and medial basilic veins that run along the arm.
Cephalic vein empties into the axillary vein and basilic
vein drain into the brachial vein. Deep veins drain into the
brachial vein that continues as the axillary and subclavian
veins. Each subclavian vein unites with the internal jugular
vein to form the right and left innominate veins. They join
together on the right side to form the superior vena cava
(SVC) that empties into the right atrium.
Venous drainage from the pelvic area flows to internal
iliac vein that joins with external iliac vein to form the
common iliac vein. Venous drainage from abdominal viscera goes to IVC. The azygous and hemiazygous system of
veins form an important link between IVC and SVC. The
hemiazygous vein and accessory hemiazygous vein is located along the left side of thoracic vertebrae and receives
blood from the left chest wall and lung and drain into the
azygous vein. In two-thirds of cases, the hemiazygous vein
communicates directly with the left renal vein. Azygous
vein is located on the right side of the thoracic vertebrae
and drains into the SVC at the level of T4. Distally, it connects to the IVC at the level of the renal vein.
Venogram
This is still considered the gold standard for VOD. Small
amount of contrast through peripherally inserted catheters
will provide visualization of the veins. Raising the arm improves central filling. For lower extremity angiography, venous access is obtained in the dorsum of the foot. DSA is
used. For iliac veins 5 to 6 F sheath is inserted in the CFV
and angiogram is obtained by hand injection of the contrast. For IVC, a pigtail or Omniflush catheter is inserted
in CIV and 40 mL of contrast is injected. For pulmonary
angiogram a 6 F angled pigtail or a Grollman catheter is
advanced in the main pulmonary artery through a sheath
in the CFV or IJ vein. Contrast at 30 mL at 15 mL/s is
injected, and angiography acquired in AP and lateral views
for each lung. If pulmonary artery pressure is high, then
selective right and left pulmonary artery angiogram is obtained. Care should be taken in patients with preexisting
LBBB because the catheter may cause RBBB, thus, causing
complete heartblock.
•
INTRAVASCULAR IMAGING
There are other intravascular imaging techniques that are
less commonly used in routine catheter peripheral angiography. They can however be very useful in cases of ambiguous situations or where a decision to intervene is not clear
cut.146
IVUS is the most widely available. IVUS catheter uses
reflected sound waves to image vascular walls and structures in a two-dimensional tomographic format. Compared
to cardiac echocardiogram, the catheters used in peripheral
imaging have a much higher frequency, 20 to 40 MHz versus 2 to 5 MHz. Most new IVUS catheters are compatible
with 6 F sheaths and guiding catheters. Over the wire and
rapid exchange systems are available. In our center we use
Boston Scientific Corp. system (Natwik, MA), unfractionated heparin at 70 units/kg is given intravenously during
IVUS procedures. Intracoronary nitroglycerin is given prior
to delivering the catheter at the area of interest. Automated
pullback is done at 0.5 to 1 mm/s. Interpretation is based
on recognition of blood–intima and media–adventitia interface. Lumina and adventitia are much brighter than the
media creating a bright–dark–bright image. Angioscopy is
not FDA-approved in the United States for clinical use.
It is probably the best technique for imaging intravascular thrombus. It provides real-time color images of vascular
surfaces and also gives information about atherosclerotic
plaque and dissection flaps. Optical coherence tomography
(OCT) generates real-time tomographic images from backscattered reflection of infrared light. It can be conceptualized as an optical analog of IVUS. It has 10 times higher resolution than conventional ultrasound. Imaging procedure
is similar to IVUS; however, saline or contrast media must
displace blood. There is only one system that is commercially available (Light bulb Imaging Inc., Westford. MA). A
0.014-inch imaging wire is inserted in the vessel distal to
the occlusion balloon. The diagnostic accuracy of OCT for
plaque characterization is confirmed by an ex vivo study of
3007 human AS specimens from aorta, carotid, and coronary arteries.147 The complications of this procedure appear
to be comparable to IVUS and angioscopy. However, data
are lacking.
•
ACKNOWLEDGMENT
We wish to thank and acknowledge all who have allowed
us to reproduce their figures and tables.
REFERENCES
1. ACC/AHA Guidelines for the Management of Patients
With Peripheral Arterial Disease (Lower Extremity, Renal,
Mesenteric, and Abdominal Aortic). A Collaborative Report
from the American Association for Vascular Surgery/Society
for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine
and Biology, Society of Interventional Radiology, and the
ACC/AHA Task Force on Practice Guidelines (Writing
Committee to Develop Guidelines for the Management of
Patients With Peripheral Arterial Disease). J Am Coll Cardiol. 2006;47(6):1239–1312.
2. Criqui MH, Denenberg JO, Langer RD, et al. The epidemiology of peripheral arterial disease: importance of identifying
the population at risk. Vasc Med. 1997;2:221–226.
3. Murabito JM, D’Agostino RB, Silbershatz H, et al. Intermittent claudication. A risk profile from The Framingham Heart
Study. Circulation. 1997;96:44–49.
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4. Isner JM, Rosenfield K. Redefining the treatment of peripheral artery disease. Role of percutaneous revascularization.
Circulation. 1993;88:1534–1537.
5. Criqui MH. Peripheral arterial disease and subsequent cardiovascular mortality: a strong and consistent association.
Circulation. 1990;82:2246–2247.
6. Hertzer NR. The natural history of peripheral vascular disease: Implications for its management. Circulation. 1991;
83(2 suppl):112–119.
7. Management of peripheral arterial disease (PAD). TASC
Working Group. Trans Atlantic Inter-Society Consensus
(TASC). J Vasc Surg. 2000;31:S1–S296.
8. Bellar GA, Bonow RO, Fuster V, et al. ACC Revised Recommendations for Training in Adult Cardiovascular Medicine
Core Cardiology Training II (COCATS 2) (Revision of the
1995 COCATS Training Statement). American College of
Cardiology, March 8, 2002.
9. White CJ, Ramee SR, Collins TJ, et al. Initial results of
peripheral vascular angioplasty performed by experienced
interventional cardiologists. Am J Cardiol. 1992;69:1249–
1250.
10. Wexler L, Levin DC, Dorros G, et al. Training standards for
physicians performing angioplasty: New developments. Radiology. 1991;178:19–21.
11. Guidelines for percutaneous transluminal angioplasty. Standards of Practice Committee of the Society of Cardiovascular
and Interventional Radiology. Radiology. 1990;177:619.
12. Guidelines for performance of peripheral percutaneous
transluminal angioplasty. The Society for Cardiac Angiography and Interventions Interventional Cardiology Committee
Subcommittee on Peripheral Interventions. Cathet Cardiovasc Diag. 1988;21:128–129.
13. Pentecost MJ, Criqui MH, Dorros G, et al. Guidelines
for peripheral percutaneous transluminal angioplasty of the
abdominal aorta and lower extremity vessels. Circulation.
1994;84:511–531.
14. Spittell JA Jr, Nanda NC, Creager MA, et al. Recommendations for peripheral transluminal angioplasty: training and facilities. American College of Cardiology Peripheral Vascular
Disease Committee. J Am Coll Cardiol. 1993;21:546–548.
flight magnetic resonance angiography with cardiac compensated fast gradient recalled echo and contrast-enhanced
three-dimensional time of flight magnetic resonance angiography. J Magn Reson Imaging. 1997;7:197–203.
21. Ruehm SG, Hany TF, Pfammatter T, et al. Pelvic and lower
extremity arterial imaging: diagnostic performance of threedimensional contrast-enhanced MR angiography. AJR Am J
Roentgenol. 2000;174:1127–1135.
22. Meaney JF, Ridgeway JP, Chakraverty S, et al. Stepping-table
gadolinium-enhanced digital subtraction MR angiography of
the aorta and lower extremity arteries: preliminary experience. Radiology. 1999;211:59–67.
23. Owen RS, Carpenter JP, Baum RA, et al. Magnetic resonance
imaging of angiographically occult runoff vessels in peripheral arterial occlusive disease. N Engl J Med. 1992;326:1577–
1581.
24. Rofsky NM, Johnson G, Adelman MA, et al. Peripheral
vascular disease evaluated with reduced-dose gadoliniumenhanced MR angiography. Radiology. 1997;205:163–169.
25. Nelemans PJ, Leiner T, de Vet HC, et al. Peripheral arterial
disease: meta-analysis of the diagnostic performance of MR
angiography. Radiology. 2000;217:105–114.
26. Khilnani NM, Winchester PA, Prince MR, et al. Peripheral
vascular disease: combined 3D bolus chase and dynamic 2D
MR angiography compared with x-ray angiography for treatment planning. Radiology. 2002;224:63–74.
27. Maintz D, Tombach B, Juergens KU, et al. Revealing in-stent
stenoses of the iliac arteries: comparison of multidetector CT
with MR angiography and digital radiographic angiography
in a phantom model. AJR Am J Roentgenol. 2002;179:1319–
1322.
28. Lee VS, Martin DJ, Krinsky GA, et al. Gadolinium–enhanced
MR angiography: artifacts and pitfalls. AJR AM J Roentgenol.
2000;175:197–205.
29. Sam AD 2nd, Morasch MD, Collins J, et al. Safety of gadolinium contrast angiography in patients with chronic renal insufficiency. J Vasc Surg. 2003;38:313–318.
30. Rubin GD, Shiau MC, Leung AN, et al. Aorta and iliac arteries: single versus multiple detector-row helical CT angiography. Radiology. 2000;215:670–676.
15. Levin DC, Becker GJ, Dorros G, et al. Training standards for
physicians performing peripheral angioplasty and other percutaneous peripheral vascular interventions. J Vasc Intervent
Radiol. 2003;9(Pt2):S359–S361.
31. Martin ML, Tay KH, Flak B, et al. Multidetector CT angiography of the aortoiliac system and lower extremities: a prospective comparison with digital subtraction angiography. AJR
Am J Roentgenol. 2003;180:1085–1091.
16. Babb JD, Collins TJ, Cowley MJ, et al. Revised guidelines for
the performance of peripheral vascular interventions. Cathet
Cardiovasc Intervent. 1999;46:21–23.
32. Willmann JK, Wildermuth S, Pfammatter T, et al. Aortoiliac and renal arteries: prospective intraindividual comparison
of contrast-enhanced three-dimensional MR angiography
and multi-detector row CT angiography. Radiology. 2003;
226:798–811.
17. ACC/ACP/SCAI/SVMB/SVS Clinical Competence Statement on Vascular Medicine and Catheter-Based Peripheral
Vascular Interventions. J Am Coll Cardiol. 2004;44(4):941–
957.
18. Rofsky NM, Adelman MA. MR angiography in the evaluation of atherosclerotic peripheral vascular disease. Radiology.
2000;214:325–338.
33. Willmann JK, Mayer D, Banyai M, et al. Evaluation of peripheral arterial bypass grafts with multi-detector row CT
angiography: comparison with duplex US and digital subtraction angiography. Radiology. 2003;229:465–474.
19. Carpenter JP, Owen RS, Holland GA, et al. Magnetic resonance angiography of the aorta, iliac, and femoral arteries.
Surgery. 1994;116:17–23.
34. Ofer A, Nitecki SS, Linn S, et al. Multidetector CT angiography of peripheral vascular disease: a prospective comparison
with intra-arterial digital subtraction angiography. AJR Am J
Roentgenol. 2003;180:719–724.
20. Quinn SF, Sheley RC, Szumowski J, et al. Evaluation of
the iliac arteries: comparison of two-dimensional time of
35. Ota H, Takase K, Igarashi K, et al. MDCT compared
with digital subtraction angiography for assessment of lower
13:35
P1: OSO/UKS
P2: OSO/UKS
QC: OSO/UKS
T1: OSO
MCGH052-20
9-780-7817-XXXX-X MCGH052-Dieter-v2
November 7, 2008
370 • CHAPTER 20
extremity arterial occlusive disease: importance of reviewing
cross-sectional images. AJR Am J Roentgenol. 2004;182:201–
209.
36. Ricker O, Duber C, Schmiedt W, et al. Prospective comparison of CT angiography of the legs with intra-arterial digital subtraction angiography. AJR Am J Roentgenol. 1996;
166:269–276.
37. Napel S, Marks MP, Rubin GD, et al. CT angiography with
spiral CT and maximum intensity projection. Radiology.
1992;185:607–610.
38. Lookstein RA. Impact of CT angiography on endovascular
therapy. Mt Sinai J Med. 2003;70:367–374
39. Rubin GD, Schmidt AJ, Logan LJ, et al. Multi-detector
row CT angiography of lower extremity arterial inflow
and runoff: initial experience. Radiology. 2001;221:146–
158.
40. Catalano C, Fraioli F, Laghi A, et al. Infrarenal aortic and
lower extremity arterial disease: diagnostic performance of
multi-detector row CT angiography. Radiology. 2004;231:
555–563.
41. Beregi JP, Djabbari M, Desmoucelle F, et al. Popliteal vascular disease: evaluation with spiral CT angiography. Radiology.
1997;203:477–483.
42. Bluemke DA, Chambers TP. Spiral CT angiography: an alternative to conventional angiography. Radiology. 1995;195:
317–319.
43. Huber PR, Leimbach ME, Lewis WL, et al. CO2 angiography. Catheter Cardiovasc Interv. 2002;55:398–403.
44. Hawkins IF. Carbon dioxide digital subtraction arteriography. AJR Am J Roentgenol. 1982;139:19–24.
45. Weaver FA, Pentecost MJ, Yellin AE, Davis S, Finck E, Teitelbaum G. Clinical applications of carbon dioxide/digital subtraction arteriography. J Vasc Surg. 1991;13:266–272.
46. Kerns SR, Hawkins IF Jr, Sabatelli FW. Current status of carbon dioxide angiography. Radiol Clin North Am. 1995;33:
15–29.
47. Kerns SR, Hawkins IF Jr. Carbon dioxide digital subtraction angiography: expanding applications and technical evolution. AJR Am J Roentgenol. 1995;164:735–741.
48. Caridi JG, Hawkins IF Jr. CO2 digital subtraction angiography: potential complications and their prevention [see comment]. J Vasc Intervent Radiol. 1997;8:383–391.
49. Hawkins IF, Caridi JG. Carbon dioxide (CO2 ) digital subtraction angiography: 26-year experience at the University
of Florida. Eur Radiol. 1998;8:391–402.
50. Sullivan KL, Bonn J, Shaprio MJ, Gardiner GA. Venography
with carbon dioxide as a contrast agent. Cardiovasc Intervent
Radiol. 1995;18:141–145.
51. Forssmann W. Die Sondierung des rechten Herzens. Klin
Wochenschr. 1929;8:2085.
52. Dos Santos R, Lama AC, Pereira-Caldas J. Arteriorgafa da
aorta e dos vasos abdominalis. Med Contempo. 1929;47:
93.
53. Bettmann MA, Heeren T, Greenfield A, et al. Adverse events
with radiographic contrast agents: results of the SCVIR Contrast Agent Registry. Radiology 1997;203:611–620.
54. Waugh JR, Sacharias N. Arteriographic complications in the
DSA era. Radiology 1992;182:243–246.
55. Baim DS. Proper use of cineangiographic equipment and
contrast agents. In: Baim DS, Grossman W, eds. Cardiac Catheterization, Angiography, and Intervention. 6th
ed. Philadelphia, PA: Lippincott, Williams, and Wilkins;
2000:15–34.
56. Balter S, Baim, DS. Cineangiographic imaging, radiation
safety and contrast agents. In: Baim DS, Grossman W, eds.
Cardiac Catheterization, Angiography and Intervention. 7th
ed. Philadelphia: Lippincott, Williams, and Wilkins; 2006:
31–33.
57. Sutton AG, Ashton VJ, Campbell PG, et al. A randomized
prospective trial of ioxaglate 320 (Hexabrix) vs. iodixanol
320 (Visipaque) in patients undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv. 2002;57:346–
352.
58. Aspelin P, Aubry P, Fransson SG, et al. Nephrotoxic effects
in high-risk patients undergoing angiography (iodixanol). N
Engl J Med. 2003;348:491–499.
59. Schwab SJ, Hlatkey MA, Pieper KS, et al. Contrast
nephrotoxicity—a randomized controlled trial of a nonionic
and an ionic radiographic contrast agent. N Engl J Med. 1989;
320:149.
60. Steinberg EP, Moore RD, Powe NR, et al. Safety and cost
effectiveness of high-osmolality as compared with lowosmolality contrast agents in patients undergoing cardiac angiography. N Engl J Med. 1992;326:425.
61. Bertrand ME, Esplugas E, Piessens J, et al. Influence of
a non-ionic, iso-osmolar contrast medium (iodixanol) versus an ionic, low-osmolar contrast medium (ioxaglate) on
major adverse cardiac events in patients undergoing percutaneous transluminal coronary angioplasty. Circulation.
2000;101:131–136.
62. Jaff MR, Macneill BD, Rosenfield K. Angiography of the
aorta and peripheral arteries. In: Baim DS, Grossman W, eds.
Cardiac Catheterization, Angiography and Intervention. 7th
ed. Philadelphia: Lippincott, Williams, and Wilkins; 2006:
257–258.
63. Millward SF, Burbridge BE, Luna G. Puncturing the pulseless femoral artery: a simple technique that uses palpation
of anatomic landmarks. J Vasc Intervent Radiol. 1993;4:415–
417.
64. Khangure MS, Chow KC, Christensen MA. Accurate and
safe puncture of a pulse less femoral artery: an aid in performing iliac artery percutaneous transluminal angioplasty.
Radiology. 1982;144:927–928.
65. Sacks D, Summers TA. Ante grade selective catheterization
of femoral vessels with a 4- or 5-F catheter and safety wire.
J Vasc Intervent Radiol. 1991;2:325–326.
66. Cohen DJ. Outpatient transradial coronary stenting: implications for cost-effectiveness. J Invasive Cardiol. 1996;8(suppl
D):36D–39D.
67. Cooper CJ, El-Shiekh RA, Cohen DJ, et al. Effects of transradial access on quality of life and cost of cardiac catheterization: a randomized comparison. Am Heart J. 1999;138:430–
436.
68. Mann T, Cowper PA, Peterson ED, et al. Transradial coronary
stenting: comparison with femoral access closed with an arterial suture device. Catheter Cardiovasc Interv. 2000;49:150–
156.
13:35
P1: OSO/UKS
P2: OSO/UKS
QC: OSO/UKS
T1: OSO
MCGH052-20
9-780-7817-XXXX-X MCGH052-Dieter-v2
November 7, 2008
PERIPHERAL ANGIOGRAPHY • 371
69. Campeau L. Entry sites for coronary angiography and therapeutic interventions: from the proximal to the distal radial
artery. Can J Cardiol. 2001;17(3):319–325.
86. Horejs D, Gilbert PM, Burstein S, Vogelzang RI. Normal aortoiliac diameters by CT. J Comput Assist Tomogr.
1988;12:602–603.
70. Campeau L. Percutaneous radial artery approach for
coronary angiography. Cathet Cardiovasc Diagn. 1989;16:
39.
87. Ebaugh JL, Garcia ND, Matsumura JS. Screening and surveillance for abdominal aortic aneurysms: who needs it and
when. Semin Vasc Surg. 2001;14:193–199.
71. Hovagim AR, Katz RI, Poppers PJ. Pulse oximetry for evaluation of radial and ulnar arterial blood flow. J Cardiothorac
Anesth. 1989;3:27–30.
88. Alcorn HG, Wolfson SK Jr, Sutton-Tyrrell K, et al. Risk factors for abdominal aortic aneurysms in older adults enrolled
in The Cardiovascular Health Study. Arterioscler Thromb Vasc
Biol. 1996;16:963–970.
72. Barry WH, Levin DC, Green LH, et al. Left heart catheterization and angiography via the percutaneous femoral approach using an arterial sheath. Cathet Cardiovasc Diagn.
1979;5:401.
73. Nath PH, Soto B, Holt JH, Satler LF. Selective coronary
angiography by translumbar aortic puncture. Am J Cardiol.
1983;52:425?
74. Hill BB, Zarins CK, Fogarty TJ. Endovascular repair of thoracic aortic aneurysms. In: White R, Fogarty T, eds. Peripheral
Endovascular Interventions. New York, NY: Springer-Verlag;
1999:383–389.
75. Arko FR, Lee WA, Hill BB. Aneurysm-related death: primary
endpoint analysis for comparison of open and endovascular
repair. J Vasc Surg. 2002;36:297–304.
76. Crawford ES, Hess KR, Sati HJ. Ruptured aneurysm of the
descending thoracic and thoracoabdominal aorta. Ann of
Surg. 1991;213:417–426.
77. Ehrlich M, Grabenwoeger M, Cartes-Zumelzu F. Endovascular stent graft repair for aneurysms on the descending thoracic aorta. Ann Thorac Surg. 1998;66:19–24.
78. Endarterectomy for Asymptomatic Carotid Artery StenosisExecutive Committee for the Asymptomatic Carotid Artery
Stenosis Study. JAMA. 1995;273:1421–1428.
79. Carotid and Cerebral Angiography Performed by Cardiologists. Cerebrovascular Complications. CCI. 2002;55:277–
280.
80. Beneficial effect of carotid endarterectomy in symptomatic
patients with high-grade carotid stenosis. North American
Symptomatic Carotid Endarterectomy Trial Collaborators.
N Engl J Med. 1991;325:445–453.
81. MRC European Carotid Surgery Trial: interim results for
symptomatic patients with severe (70%-99%) or with
mild (0%-29%) carotid stenosis. European Carotid Surgery
Trialists’ Collaborative Group. Lancet. 1991;337:1235–
1243.
82. Casserly IP, Yadav JS. Carotid intervention. In: Yadav JS,
Casserly Ip, Sachar R, eds. Manual of Peripheral Vascular Interventions. Philadelphia, PA: Lippincott Williams, &
Wilkins; 2005:84–86.
89. Pedersen OM, Aslaksen A, Vik-Mo H. Ultrasound measurement of the luminal diameter of the abdominal aorta and
iliac arteries in patients without vascular disease. J Vasc Surg.
1993;17:596–601.
90. Lanne T, Sandgren T, Sonesson B. A dynamic view on the diameter of abdominal aortic aneurysms. Eur J Vasc Endovasc
Surg. 1998;15:308–312.
91. Johnston KW, Rutherford RB, Tilson MD, et al. Suggested
standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc
Committee on Reporting Standards, Society for Vascular
Surgery and North American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg. 1991;13:452–
458.
92. Krupski WC, Selzman CH, Floridia R, et al. Contemporary management of isolated iliac aneurysms. J Vasc Surg.
1998;28:1–11; discussion 11–13.
93. Kasirajan V, Hertzer NR, Beven EG, et al. Management of
isolated common iliac artery aneurysms. Cardiovasc Surg.
1998:6:171–177.
94. Rubin GD, Armerding MD, Dake MD, et al. Cost identification of abdominal aortic aneurysm imaging by using time
and motion analysis. Radiology. 2000;215:63–70.
95. Turnipseed WD, Archer CW, Detmer DE, et al. Digital subtraction angiography and B-mode ultrasonography for abdominal and peripheral aneurysms. Surgery. 1982;92:619–
626.
96. Bandyk DF. Preoperative imaging of aortic aneurysms: conventional and digital subtraction angiography, computed tomography scanning, and magnetic resonance imaging. Surg
Clin North Am. 1989;69:721–735.
97. Galt SW, Pearce WH. Preoperative assessment of abdominal
aortic aneurysms: noninvasive imaging versus routine arteriography. Semin Vasc Surg. 1995;8:103–107
98. Hallett JW Jr. Splenic artery aneurysms. Semin Vasc Surg.
1995;8:321–326.
99. Kasirajan K, Greenberg RK, Clair D, et al. Endovascular
management of visceral artery aneurysm. J Endovasc Ther.
2001;8:150–155.
83. Mukherjee D, Rosenfield K. Vertebral artery disease. In:
Yadav JS, Casserly Ip, Sachar R, eds. Manual of Peripheral
Vascular Interventions. Philadelphia, PA: Lippincott Williams
& Wilkins; 2005:110–111.
100. Angelakis EJ, Bair WE, Barone JE, et al. Splenic artery
aneurysm ruptured during pregnancy. Obstet Gynecol Surv.
1993;48:145–148.
84. Phatouros CC, Higashida RT, Malek AM, et al. Endovascular
treatment of noncarotid extra cranial cerebrovascular disease.
Neurosurg Clin N Am. 2000;11(2):331–350.
101. Holley KE, Hunt JC, Brown AL Jr, et al. Renal artery stenosis:
a clinical–pathologic study in normotensive and hypertensive
patients. Lancet. 1964;37:14–22.
85. Gabella G. Cardiovascular System. In: Williams PL, Bannister LH, Berry MM, eds. Gray’s Anatomy. New York, NY:
Churchill Livingstone; 1995:1505–1546.
102. Dustan HP, Humphries AW, Dewolfe VG, et al. Normal arterial pressure in patients with renal arterial stenosis. JAMA.
1964;187:1028–1029.
13:35
P1: OSO/UKS
P2: OSO/UKS
QC: OSO/UKS
T1: OSO
MCGH052-20
9-780-7817-XXXX-X MCGH052-Dieter-v2
November 7, 2008
372 • CHAPTER 20
103. Scoble JE. The epidemiology and clinical manifestations
of atherosclerotic renal disease. In: Novick AC, Scoble JE,
Hamilton G, eds. Renal Vascular Disease. London, UK: WB
Saunders; 1996:303–314.
119. Halperin EJ, Rutter CM, Gardiner GA Jr, et al. Comparison
of Doppler US and CT angiography for evaluation of renal
artery stenosis. Acad Radiol. 1998;5:524–532.
104. Hansen KJ, Edwards MS, Craven TE, et al. Prevalence of
renovascular disease in the elderly: a population based study.
J Vasc Surg. 2002;36:443–451.
120. Johnson PT, Halpern EJ, Kuszyk BS, et al. Renal artery
stenosis: Ct angiography—comparison of real-time volumerendering and maximum intensity projection algorithms. Radiology. 1999;211:337–343.
105. Olin JW, Melia M, Young JR, Graor RA, Risius B. Prevalence of atherosclerotic renal artery stenosis in patients with
atherosclerosis elsewhere. Am J Med. 1990;88:46–51.
121. Kim TS, Chung JW, Park JH, et al. Renal artery evaluation:
comparison of spiral CT angiography to intra-arterial DSA.
J Vasc Interv Radiol. 1998;9:553–559.
106. Harding MB, Smith LR, Himmelstein SI, et al. Renal artery
stenosis: prevalence and associated risk factors in patients undergoing routine cardiac catheterization. J Am Soc Nephrol.
1992;2:1608–1616.
122. Rubin GD, Duke MD, Napel S, et al. Spiral CT of renal
artery stenosis: comparison of three-dimensional rendering
techniques. Radiology. 1994;190:181–189.
107. Weber-Mzell D, Kotanko P, Schumacher M, et al. Coronary
anatomy predicts presence or absence of renal artery stenosis:
a prospective study in patients undergoing cardiac catheterization for suspected coronary artery disease. Eur Heart J.
2002;23:1684–1691.
108. Jean WJ, al-Bitar I, Zwicke DL, et al. High incidence of renal artery stenosis in patients with coronary artery disease.
Cathet Cardiovasc Diag. 1994;32:8–10.
109. Scoble JE, Maher ER, Hamilton G, Dick R, Sweny P, Moorhead JF. Atherosclerotic renovascular disease causing renal impairment—a case for treatment. Clin Nephrol. 1989;
31:119–122.
110. Zierler RE, Bergelin RO, Isaacson JA, Strandness DE.
Natural history of atherosclerotic renal artery stenosis: A
prospective study with duplex ultrasonography. J Vasc Surg.
1994;19:250–258.
111. Wright JR, Shurrab AE, Cheung C, et al. A prospective study
of the determinants of renal functional outcome and mortality in atherosclerotic renovascular disease. Am J Kidney Dis.
2002;39(6):1153–1161.
112. Suresh M, Laboi P, Mamtora H, et al. Relationship of
renal dysfunction to proximal arterial disease severity in
atherosclerotic renovascular disease. Nephrol Dial Transplant. 2000;15(5):631–636.
113. Rimmer JM, Gennari FJ. Atherosclerotic renovascular disease and progressive renal failure. Ann Intern Med. 1993;
118:712–719.
114. Mailloux LU, Napolitano B, Bellucci AG, et al. Renal vascular disease causing end-stage renal disease, incidence, clinical
correlates, and outcomes: a 20-year clinical experience. Am
J Kidney Dis. 1994;24:622–629.
115. Guzman RP, Zierler RE, Isaacson JA, et al. Renal atrophy
and arterial stenosis. A prospective study with duplex ultrasound. Hypertension. 1994;23:346–350.
116. Caps MT, Zierler RE, Polissar NL, et al. Risk of atrophy in
kidneys with atherosclerotic renal artery stenosis. Kidney Int.
1998;53:735–742.
117. Mitsuzaki K, Yamashita Y, Sakaguchi T, et al. Abdomen, pelvis, and extremities: diagnostic accuracy of dynamic contrast-enhanced turbo MR angiography compared
with conventional angiography-initial experience. Radiology.
2000;216:909–915.
118. Beregi JP, Elkohen M, Deklunder G, et al. Helical CT angiography compared with arteriography in the detection of renal
artery stenosis. AJR Am J Roenrtgenol. 1996;167:495–501.
123. Kawashima A, Sandler CM, Ernst Rd, et al. CT evaluation
of renovascular disease. Radiographics. 2000;20:1321–1340.
124. Lufft V, Hoogestraat-Lufft L, Fels LM, et al. Contrast
media nephropathy: intravenous CT angiography versus
intra-arterial digital subtraction angiography in renal artery
stenosis: a prospective randomized trial. Am J Kidney Dis.
2002;40:236–242.
125. Rihal CS, Textor SC, Grill DE, et al. Incidence and prognostic importance of acute renal failure after percutaneous coronary intervention. Circulation. 2002;105:2259–
2264.
126. Parfrey PS, Griffiths SM, Barrett BJ, et al. Contrast materialinduced renal failure in patients with diabetes mellitus, renal
insufficiency or both. A prospective controlled study. N Engl
J Med. 1989;320:143–149.
127. Aspelin P, Aubry P, Fransson SG, et al. Nephrotoxic effects
in high-risk patients undergoing angiography. N Engl J Med.
2003;348:491–499.
128. Kay J, Chow WH, Chan TM, et al. Acetylcysteine for prevention of acute deterioration of renal function following
elective coronary angiography and intervention: a randomized controlled trial. JAMA. 2003;289:553–558.
129. Ottinger LW, Austin WG. A study of 136 patients with
mesenteric infarction. Surg Gynecol Obstet. 1967;124:251–
261.
130. Hertzer NR, Beven EG, Humphries AW. Acute intestinal
ischemia. Ann Surg. 1978;44:744–749.
131. Bergan JJ. Recognition and treatment of intestinal ischemia.
Surg Clin North Am. 1967;47:109–126.
132. Mikkelsen WP. Intestinal angina: its surgical significance. Surg
Gynecol Obstet. 1957;94:262–267; discussion, 267–269.
133. Buchardt Hansen HJ. Abdominal angina: results of arterial
reconstruction in 12 patients. Acta Chir Scand. 1976;142:
319–325.
134. Fisher DF Jr, Fry WJ. Collateral mesenteric circulation. Surg
Gynecol Obstet. 1987;164:487–492.
135. Kawauchi M, Tada Y, Asano K, et al. Angiographic demonstration of mesenteric arterial changes in postcoarctectomy
syndrome. Surgery. 1985;98:602–604.
136. Siegelman SS, Sprayregen S, Boley SI. Angiographic diagnosis of mesenteric arterial vasoconstriction. Radiology
1974;112:533–542.
137. Nalbandian H, Sheth N, Dietrich R, et al. Intestinal ischemia
caused by cocaine ingestion: report of two cases. Surgery.
1985;97:374–376.
13:35
P1: OSO/UKS
P2: OSO/UKS
QC: OSO/UKS
T1: OSO
MCGH052-20
9-780-7817-XXXX-X MCGH052-Dieter-v2
November 7, 2008
PERIPHERAL ANGIOGRAPHY • 373
138. Vitale GF, Inahara T. Extra peritoneal endarterectomy for iliofemoral occlusive disease. J Vasc Surg. 1990;12:409–413;
discussion 414–415.
139. van den Dungen JJ, Boontje AH, Kropveld A. Unilateral iliofemoral occlusive disease: long-term results of the semiclosed endarterectomy with the ring-stripper. J Vasc Surg.
1991;14:673–677.
140. de Vries SO, Hunink MG. Results of aortic bifurcation grafts
for aortoiliac occlusive disease: a meta-analysis. J Vasc Surg.
1997;26:558–569.
141. Cambria RP, Yucel EK, Brewster DC, et al. The potential for
lower extremity revascularization without contrast arteriography: experience with magnetic resonance angiography. J
Vasc Surg. 1993;17:1050–1056.
142. Sueyoshi E, Sakamoto I, Matsuoka Y, et al. Aortoiliac and
lower extremity arteries: comparison of three-dimensional
dynamic contrast-enhanced subtraction MR angiography
and conventional angiography. Radiology. 1999;210:683–
688.
143. Poletti PA, Rosset A, Didier D. Subtraction CT angiography of the lower limbs: a new technique for the evaluation of acute arterial occlusion. AJR Am J Roentgenol.
2004;183:1445–1448.
144. Legemate DA, Teeuwen C, Hoeneveld H, Eikelboom BC.
Value of duplex scanning compared with angiography and
pressure measurement in the assessment of aortoiliac arterial lesions. Br J Surg. 1991;78:1003–1008.
145. Fraser DG, Moody AR, Davidson IR, et al. Deep venous
thrombosis: Diagnosis by using venous enhanced subtracted
peak arterial MR venography versus conventional venography. Radiology. 2003;226(3):812–820.
146. Honda Y, Fitzgerald PJ, Yock PG. Intravascular Imaging techniques. In: Baim DS, Grossman W, eds. Cardiac Catheterization, Angiography and Intervention. 7th edition; Philadelphia,
PA: Lippincott Williams & Wilkins; 2006:371–391.
147. Yabushita H, et al. Characterization of human atherosclerosis by optical coherence tomography. Circulation. 2002;106:
1640–1645.
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